Research-Based Insights into Increasing the Global Supply and Affordability of Donor Milk

• The efficacy of lactoengineered products. Although the efficacy of pasteurized donor milk is well established, limited research exists regarding the effectiveness of lactoengineered human milk fortifiers. ⁴ This is an important area for future research and requires study designs that allow us to distinguish the benefits of donor milk alone, compared with donor milk supplemented with lactoengineered products (something the existing body of research has not yet done). We know that bioactive compounds in milk are fragile and that there is partial loss in pasteurization. How does the manufacturing process of human milk fortifiers potentially alter these bioactive compounds and the benefits they confer? Understanding how to supplement human milk to meet the unique nutritional needs of the very fragile infant is a very important research topic. Future research should evaluate both short- and long-term health outcomes associated with fortification.

• The role of the medical community in increasing milk supply. Medo states that there is no credible evidence that healthcare professionals can play a role in increasing the supply of donor milk, yet existing research suggests that healthcare professionals are potentially a powerful influencer. Brazil's milk bank system produces five times the volume of donor milk per preterm infant than the U.S. system. ⁵ A study of more than 700 donors in Brazil found that the top reason women donated milk was because it was encouraged by a healthcare professional (61.3%), ⁶ whereas a study of 87 donors in the United States found only 14% of donors got involved with milk banking because they were referred by a healthcare professional. ⁷ Donor milk must become a standard part of the healthcare conversation if the United States is going to create a supply of donor milk to meet the needs of all fragile infants. Existing research suggests that healthcare professionals can be a critical part of that conversation, yet in the United States they remain an underutilized referral source.

• The value of paying donors for milk. Are milk donors seeking to “leverage an asset they own,” as Medo suggests, or are for-profit companies seeking to leverage this asset? No published research exists on this specific question or on Medo's claim that women would delay their return to work and breastfeed longer if they were paid for their milk. Some insights can be gained from studies with online milk sharers ⁸ and milk bank donors ⁷ that suggest the primary motivator for these women was knowing that their milk was helping someone. Medo also asks, “Why are women willing to share with one another on a large scale but not with established milk banks?” Recent research by Gribble ⁸ found that the top reason milk sharers did not give to a milk bank was because there wasn't one in their geographic area. The 16 milk banks of the Human Milk Banking Association of North America (HMBANA) accept donors from everywhere in the United States and pay the costs to safely ship the milk to the bank for processing. This gap in donor knowledge suggests that mothers are not fully aware of all of their options for donating milk and further supports the need to relay this important message via healthcare professionals. The risk of paying donors (adulteration, diverting milk from their child) warrants more research into whether compensation is an effective approach for creating an adequate and affordable supply of donor milk.

• The cost of donor milk. Medo states that the cost of donor milk is preventing widespread use, yet also proposes increasing costs by paying donors. HMBANA milk banks serve 50 states in the United States (Fig. 1), and the cost of donor milk ranges from $3 to $5 per ounce, while the cost of pasteurized donor milk from for-profit companies costs $14 per ounce. A 2013 study of Level 3 neonatal intensive care units (NICUs) in the United States showed that 39% of hospitals did not think donor milk was affordable. ³ Research shows that human milk use in the NICU results in significant cost savings to hospitals. ⁹ As the conversation is shifted from milk cost to healthcare savings, we believe that NICU use of pasteurized donor milk will continue to rise.