Today, it is no longer remains a question about whether breast milk is best for babies. If anyone has doubts, there are multiple sources and examples of how breast milk is better for all babies, but particularly for our premature infants in the NICU.
Some examples for term, healthy babies are reduction of incidences and severity of infections; prevention of allergies; possible enhancement of cognitive development; and prevention of obesity, hypertension and insulin-dependent diabetes mellitus.1-3 For premature babies, it has been shown that breast milk provides additional immunity at a time when they are not able to mount their own immunity. While this is beneficial for any baby, it is particularly important for a preterm infant. In addition, much of the research specific to preterm infants focuses on prevention of necrotizing enterocolitis, a problem not usually encountered in the term infant. In addition, breast milk is simply better tolerated in the premature infant, usually resulting in less frequent periods of nothing per os when inadequate nutrition might be offered.4 In my own experience, I have encountered mothers who delivered a premature infant who did not intend to breast feed but once they heard about the benefits of breast milk, they agreed to pump and provide milk for at least the first 2 weeks, the most critical time. Many ultimately ended up providing breast milk until at least discharge or as long as they were able to produce.
Production of breast milk over the sometimes long term that infants spend in the NICU can be challenging. There are many ways that mothers’ can be supported in their efforts. However, this is a very high stress time for many mothers and poor diet, lack of sleep and stress are not conducive to good milk supply. Ultimately, many mothers, particularly of very premature infants (less than 28 weeks) are unable to maintain an adequate milk supply until the infant reaches term gestation. With the ever-mounting evidence that mother’s own milk is best for particularly these very vulnerable infants, donor milk banks are becoming quite busy and more are now in operation or starting operation in an attempt to meet the needs of these infants. Guidelines by which most of these banks operate can be found in the Human Milk Banking Association of North America (HMBANA) Best Practices.5 This document can be purchased at www.hmbana.org Based on the best available evidence, recommendations are made for the pumping, storage and handling of breast milk. These recommendations are specific to in-hospital vs in the home and there is a separate book for establishing a donor milk bank.
Many of you are probably already using donor milk for at least some babies in your NICU. Since mothers often cannot provide sufficient milk, donor milk may be made available to them or in some cases, they may want to or are asked to purchase it for their infant. While donor milk may be beneficial for premature infants and is recommended by the American Academy of Pediatrics, there is not yet strong scientific evidence in the form of a randomized controlled trial to support this.6 Donor milk is not equivalent to mother’s own milk, this is known. Nutritional content and immune globulins in mother’s milk will vary over time. Immunity provided is, of course, specific to her own body and organisms that the infant is likely to be exposed to in the home setting. Nutrition provided in the first few weeks, or what might be referred to as “premature” milk, is nutritionally higher in fat and protein, lower in lactose as well as being higher in immune globulins. This provides a diet that is easily tolerated and digested in the premature infant during the first few days of life. As time goes by, the milk will become nutritionally equivalent to “term” milk with less calcium, protein and fat than is needed by the growing premature infant who must now grow at a rate to match fetal growth based on their own intake. Most donor milk is nutritionally equivalent to “term” milk and therefore, often needs fortification in order to provide adequate nutrients.7 In addition, donor milk is pasteurized and processed. Many studies have evaluated the effect of the pasteurization method recommended by the HMBANA (the Holder Pasteurization method) and its effect on the milk. Studies show that this method of pasteurization is an effective means to remove bacteria from the donor milk but preserves most nutrients and immune factors.8
Recently, with the increase in demand for breast milk, there seems to have been an increase in availability of donor milk from unreliable sources or maybe I’ve just become more aware of it! In a recent article, Keim et al collected breast milk that they purchased via the internet.9 These purchases were from individuals and not from a donor bank. The samples were cultured and results compared to unpasteurized maternal milk donated to a donor milk bank. Significantly more bacteria was found in the samples purchased via the internet (shipping was not standardized). This is not pasteurized either so the bacteria will not be eradicated before being fed to an infant. In addition, the presence of CMV in the milk was far more prevalent in the milk purchased via the internet (21% vs 5%). Health screening is recommended and required by any donor milk bank. Lab results may also be required prior to donating as well as on an ongoing basis if milk is donated over a prolonged time period. None of this is available for milk purchased via the Internet except through the mother’s own word. Furthermore, the HMBANA guidelines for banking of donor milk do not recommend that mother’s be paid for the milk they donate. Charges to the recipient for the milk are simply to cover the costs of processing and shipping the milk. This prevents women from donating milk that may not meet the requirements simply for pay. However, recently, a partnership between the Mother’s Milk Co-op and Medolac Laboratories (http://www.medolac.com/press-releases.html) has been formed that is paying women to donate their milk (“a fair compensation”). Furthermore, this milk will then be pasteurized and stored in foil pouches that have a 3-year shelf-life without required refrigeration! This is like astronaut food for preemies!! So, what does this do to the nutritional contents and most importantly, the immune properties of the milk? It appears that question is as yet unanswered. The concept of having milk that doesn’t expire quickly and doesn’t need to stay frozen during shipment is an attractive one but we need evidence that this is at least as good as any other donor milk. Indeed, what is the future of milk for preemies?
Note: When Acacia inquired with Adrianne Weir, CEO of Mothers Milk Cooperative, she explained, “Co-op Donor milk is less expensive, especially when factoring in handling charges and the overnight shipping that is required for frozen donor milk. Co-Op Donor milk is heat treated and stored in foil pouches that have a 3-year shelf-life without required refrigeration, which is only possible because the donor milk is commercially sterile. Co-op Donor Milk includes a nutritional facts panel specific to each lot, providing important information on protein, fat and carbohydrate content and there is no evidence that its heat processing technique impacts the immune properties of the milk any more than Holder Pasteurization heat processing.” Learn more about Mothers Milk Cooperative here.
1. Leung AKC, Sauve RS. Breast is best for babies. Journal of the National Medical Association. 2005-97(7):1010-1019. Available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2569316/
2. Oddy WH. Long-term health outcomes and mechanisms associated with breastfeeding. Expert Rev Pharmacoecon Outcomes Res. 2002;2(2):161-177.doi: 10.1586/14737188.8.131.52.
3. Evenhouse E, Reilly S. Improved estimates of the benefits of breastfeeding using sibling comparisons to reduce selection bias. Health Serv Res. 2005;40(6Pt1):1781-1802
4. Henderson G, Anthony MY, McGuire W. Formula milk versus maternal breast milk for feeding preterm or low birth weight infants. Cochrane Database of Systematic Reviews 2007, Issue 4. Art. No.: CD002972. DOI: 10.1002/14651858.CD002972.pub2 – Seemore at: http://summaries.cochrane.org/CD002972/formula-milk-versus-maternal-breast-milk-for-feeding-preterm-or-low-birth-weight-infants#sthash.CEgVcF1v.dpuf
5. Jones F. & Human Milk Banking Association of North America. Best practices for expressing storing and handling human milk in hospitals, homes, and child care settings. 3rd ed. Human Milk Banking Association of North America:Fort Worth, TX. 2011.
6. American Academy of Pediatrics Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 2012;129:e827. Doi:10.1542/peds.2011-3552
7. Schanler RJ. The use of human milk for premature infants. Pediatr ClinNorth Am. 2001;48:207–219
8. Landers S, Undegrove K. Bacteriological screening of donor human milk before and after Holder pasteurization. Breastfeeding Medicine. 2010;5(3):117-121.doi: 10.1089/bfm.2009.0032.
9. Keim SA, Hogan JS, McNamara KA, Gudimetla V, Dillon CE, Geraghty K, Geraghty SR. Microbial contamination of human milk purchased via the internet. Pediatrics 2013;132:e1227.
Read more on breast milk feeds for NICU patients:
View Sandy Beauman’s blog entry, Warming of Infant Feedings.