Where Does Donor Milk Banking Fit in Public Health Policy?
Lois W. Arnold, MPH, IBCLC from BREASTFEEDING ABSTRACTS, February 2002, Volume 21, Number 3, pp. 19-20.
In 1980 the World Health Organization and UNICEF issued the following joint statement:
Where it is not possible for the biological mother to breastfeed, the first alternative, if available, should be the use of human breast milk from other sources. Human milk banks should be made available in appropriate situations1 [Italics added by author].
Even after the publication of reports that HIV could be transmitted through human milk, WHO and UNICEF continued to make positive statements about donor milk banking:
When a baby is to be artificially fed, the choice of feeding method and product should not be influenced by commercial pressures. If donor milk is to be used, it must first be pasteurized, and where possible, donors should be screened for HIV.2
Donor milk banking also plays a role in another WHO/UNICEF initiative, The Baby-Friendly Hospital Initiative. Donor milk banking can be applied to six of the Ten Steps to Successful Breastfeeding. Written breastfeeding policies in the hospital should list donor milk as an alternative feeding (Step 1) and all staff in the hospital should be trained to implement the policies relating to the use of donor milk (Step 2). All pregnant women should be informed of the benefits of human milk and how important it is for infants to have human milk as first feedings, using donor milk if no maternal milk is available (Step 3). All mothers should be shown how to express their milk (Step 5), and hospital staff should provide no food or drink other than human milk, with donor milk being used in preference to formula when supplementation is needed (Step 6). This means that the Baby-Friendly Hospital should have a supply of donor milk on hand, making it as easy to pull off the shelf as formula. Step 10 deals with community support of mothers. Part of community support should be knowing where donor milk banking resources are and helping mothers to access them, either to become donors or as the mother of a potential recipient.3
There are also policy documents in place within the US which could support donor milk banking services. While donor milk banking is not specifically mentioned, it is an integral part of the policies relating to the importance of breastfeeding and human milk. For example, the Healthy People 2010 Goals for the Nation place an emphasis on prevention of morbidity through an increase in breastfeeding rates.4 When used clinically, donor milk has comparable potential for preventing and reducing morbidity and mortality.
The last policy statement from the American Academy of Pediatrics to deal exclusively with donor milk was in 1980, pre-HIV.5 While this statement has not been updated, other more recent references to donor milk banking in AAP publications such as the Pediatric Nutrition Handbook, Guidelines for Perinatal Care, and the Red Book on Infectious Disease have become replacement policy statements.6, 7, 8 They specify that anyone using donor milk should follow the voluntary guidelines established by the Human Milk Banking Association of North America.
Perhaps the most powerful AAP policy statement which addresses donor milk usage indirectly is the 1997 breastfeeding statement.9
Human milk is uniquely superior for infant feeding and is species specific; all substitute feeding options differ markedly from it.
"Human milk is the preferred feeding for all infants, including premature and sick newborns, with rare exceptions. When direct breastfeeding is not possible, expressed human milk, fortified when necessary for the premature infant, should be provided.
Donor milk is one way to obtain expressed milk and remains species specific despite some immunological losses during processing."
The most recent policy statement into which donor milk is easily incorporated is the Strategic Plan from the US Breastfeeding Committee.10 The first goal in the Strategic Plan is to “assure access to comprehensive, current, and culturally appropriate lactation care and services for all women, children, and families.” Donor milk banks are a lactation service, providing human milk when a mother has been unable to supply her own. Most milk banks in the US also provide lactation support in the form of counseling to donors and others in communities far and wide. Strategies for implementing the first goal of the Strategic Plan include education of health care providers as well as reimbursement by third parties of lactation services. This means that milk banks themselves must take a lead role in the collection of data and the education of health care providers and insurers, as MacPherson and Talbot stated in 1939:
"The milk bank also has the opportunity to educate physicians and medical students and nurses, by means of lectures and personal interviews. This should be one of its duties whenever the opportunity arises because of the tendency today to overemphasize the ease of feeding with cow’s milk mixtures."11
With so many places for donor milk to fit in the public health policy picture, why are we making so little progress in the US with donor milk banking? Why does Brazil, for example, have a milk banking system that is rapidly growing while in the US milk banking is rapidly losing ground? Politics, lack of funding, and lack of direction from agencies within the federal government combine to make milk banking very difficult in the US. More money needs to be put into breastfeeding and milk banking from all sectors of healthcare funding. Milk banks in the US also need to be federally regulated so that they can gain the trust and confidence of the healthcare community. Federal agencies such as the Centers for Disease Control (CDC), the Department of Agriculture (USDA), and the Food and Drug Administration (FDA) need to decide on jurisdictional issues and develop a cohesive plan of action relating to donor milk banking. Milk banks also need to collect better data and publish studies on clinical uses of donor milk in order to demonstrate need for the service and cost-effectiveness. Only then will we turn the tide and start growing milk banking again in the US.
Lois D. W. Arnold is the former Executive Director of the Human Milk Banking Association of North America and is the President of the National Commission on Donor Milk Banking. She is an administrative consultant to Baby-Friendly USA and is a co-author of the recently published Reclaiming Breastfeeding for the United States.
1. World Health Organization/United Nations Children's Fund. Meeting on infant and young child feeding. J Nurs Midw 1980; 25:31-38.
2. World Health Organization/United Nations Children's Fund. Consensus statement from the WHO/UNICEF consultation on HIV transmission and breastfeeding. April 30-May 1, 1992, Geneva.
3. World Health Organization/United Nations Children's Fund. Protecting, promoting, and supporting breastfeeding: The special role of maternity services. A Joint WHO/UNICEF Statement. Geneva: WHO, 1989.
5. American Academy of Pediatrics Committee on Nutrition. Human milk banking. Pediatrics 1980; 65:854-57.
6. American Academy of Pediatrics Committee on Nutrition. Pediatric Nutrition Handbook, 4th ed. Elk Grove Village, IL: AAP, 1998, pp. 15-16.
7. American Academy of Pediatrics Committee on Fetus and the Newborn and American College of Obstetrics and Gynecology Committee on Obstetric Practice. Guidelines for Perinatal Care, 4th ed. Elk Grove Village, IL: AAP, 1997, pp. 288-90.
8. American Academy of Pediatrics Committee on Infectious Diseases. 1997 Red Book, 24th ed. Elk Grove Village, IL: AAP, 1997, pp. 76-77.
9. American Academy of Pediatrics Work Group on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics 1997; 100(6):1035-39.
10. United States Breastfeeding Committee. Breastfeeding in the United States: A National Agenda. Rockville, MD: MCH Bureau, Health Resource and Services Administration, DHHS, 2001.
11. MacPherson, C. and F. Talbot. Standards for directories for mother’s milk. J Pediatr 1939; 15:461-68.