Abstract
Abstract
There is a paucity of literature on the topic of banked donor breastmilk use for healthy newborns. Herein, we describe two cases demonstrating the day-to-day medically indicated use of pasteurized, banked donor breastmilk in the University of Iowa Children's Hospital newborn nursery. These cases may inform scientific opinion about the role of banked donor milk for healthy newborns and may also facilitate research on the use of banked donor milk for this population.
Introduction
E
It is known that exclusive breastfeeding confers many advantages over formula feeding, including better neurodevelopmental outcomes and a reduced risk of multiple childhood and chronic diseases such as gastrointestinal infections, lung infections, ear infections, diabetes, celiac disease, leukemia, sudden infant death syndrome, and obesity. 2 Additionally, exposure to formula, even in limited amounts supplementing otherwise breastfed infants, has been associated with adverse health outcomes, including early breastfeeding cessation, 4 increased risk of hypertrophic pyloric stenosis,5,6 allergic disease, 7 and early childhood obesity. 8 Health benefits of donor breastmilk supplementation, rather than formula, in term newborns have not been scientifically evaluated, but benefits have been shown in preterm infants, most notably a decreased risk of necrotizing enterocolitis.9,10 There is currently an ongoing clinical trial at our institution investigating the effect of donor milk supplementation versus formula supplementation on neurodevelopmental outcomes and late-onset sepsis among very low-birth-weight infants (registered at ClinicalTrials.gov with clinical trial registration number NCT01232725).
In 2006, with funding provided by a grant from the Children's Miracle Network, the mother baby care unit/newborn nursery at the University of Iowa began offering pasteurized donor milk from the Mother's Milk Bank of Iowa as a supplementation choice. After 3 years of grant funding, the mother baby care unit began paying for donor milk as a portion of its nutrition budget. This inpatient donor milk expense is not reimbursed by insurance. Donor human milk supplementation for all infants needing supplementation, both sick and well, is now a standard of care practice throughout the University of Iowa Children's Hospital. Our institution maintains a nursing policy regarding breastfeeding promotion, support, and protection, and nurses do not provide formula or donor breastmilk to infants unless by physician order, with parents ultimately deciding which supplement is used for their children. In keeping with best practices, physicians, nurses, and lactation consultants in our nursery strive to educate parents of the benefits of breastfeeding and advise mothers against supplementing when it is not medically indicated. If donor milk supplementation is medically indicated, because of infant hypoglycemia, excessive neonatal weight loss (with no set guideline; it is at the prescribing provider's discretion), twin or higher-level multiple delivery with the mother receiving lactation support, late-preterm infants who require supplementation, or other indication as determined by the infant's healthcare providers, then the infant's physician or nurse practitioner obtains a signed donor milk agreement from one of the infant's parents.
Case Reports
Case 1
A 39 4/7-week, 2,685-g, small-for-gestational-age male infant was born by cesarean section because of arrest of fetal descent and fetal distress to a 26-year-old first-time mother. Delivery was also complicated by maternal chorioamnionitis and meconium-stained amniotic fluid; his Apgar scores were 4 and 7. He had initial bradycardia, which resolved with positive pressure ventilation, and because of mild respiratory distress, he was admitted to the transition nursery for observation while his mother remained in surgery.
Because he was small for gestational age, he was placed on our institution's hypoglycemia protocol for blood glucose monitoring. Once glucose monitoring began, his parents were asked whether they would prefer donor breastmilk or formula if the baby required supplementation. The parents requested breastmilk, and the father signed an agreement for banked donor milk. The infant's initial blood sugar level was 33 mg/dL, so his physician ordered 20 mL of donor milk, as his mother was still in surgery. The patient's blood sugar level 30 minutes after feeding was 60 mg/dL. Subsequent blood glucose readings were all above 45 mg/dL. An intravenous line was placed, antibiotics were started, and his initial respiratory distress resolved.
When his mother was available for breastfeeding, the baby was transferred to room-in with her. She began breastfeeding him, supplementing with donor milk 5–10 mL per feeding initially to help prevent hypoglycemia, and she began pumping. He received a total volume of 45 mL of donor breastmilk during his birth hospitalization. He remained inpatient for intravenous antibiotics for sepsis treatment for 7 days, and his mother continued to breastfeed him frequently, supplementing intermittently with her own expressed breastmilk. At the time of hospital discharge he was down only 0.5% from birth weight and was exclusively breastfeeding 10–12 times daily. He was discharged home without a prescription for donor milk and never received formula. He was exclusively breastfeeding at the time of his 2-week well child exam.
Case 2
A 36 1/7-week late-preterm infant was born by normal spontaneous vaginal delivery following preterm premature rupture of membranes to a 27-year-old first-time mother. The pregnancy was complicated by type 1 diabetes, and the mother was on an insulin infusion during delivery. The baby's Apgar scores were 8 and 9, but because of respiratory distress beginning shortly after birth, he was transferred to the transitional care nursery.
Because of prematurity and maternal diabetes, he was started on our institution's hypoglycemia protocol. At the time of his admission to the transitional care nursery, his mother had been asked for consent to use donor milk, if he should require supplementation. His mother did not feel strongly whether he received formula or donor milk, but when she was informed that donor milk is the usual standard of care at our institution and is the recommendation of the ABM and AAP, she readily agreed to donor milk. His initial blood sugar level was 67 mg/dL, so he was not supplemented. His respiratory distress quickly resolved, and he transferred to the mother baby unit to room-in with his mother at 2 hours of age.
When attempting to breastfeed, he demonstrated difficulty latching and had a weak suck, and his mother was noted to have flat, borderline inverted nipples. He had not yet successfully latched at 9 hours of life despite the help of our lactation consultant, so the decision was made to provide syringe feedings with donor breastmilk after each breastfeeding attempt. With the help of a nipple shield, his mother was able to get him to latch; over the next 24 hours he took 5–15 mL of donor milk by syringe every 2–3 hours following feedings at the breast, and his mother pumped after each feeding. He took a total of 147 mL of donor breastmilk during his 2-day hospital stay.
He was discharged home with 600 mL of donor breastmilk to facilitate continued supplementation as needed prior to maternal mature milk production. His mother's insurance would support up to a 3-month supply of donor breastmilk if needed to augment her own supply, and this was discussed with his mother. At the time of hospital discharge on postnatal Day 2, his mother was pumping small volumes of milk after each feed, he was latching with the nipple shield and supplementing with mother's milk plus donor milk to equal 15–20 mL after each feed, and he was down 6% from his birth weight and mildly jaundiced. One week after discharge he was exclusively breastmilk fed, primarily with his mother's pumped milk, his jaundice was improving without phototherapy, and his mother was still working with a lactation consultant to help with latch concerns.
Discussion
These two cases illustrate how the University of Iowa Children's Hospital utilizes donor human milk to supplement infants who are not ill enough to require admission to the neonatal intensive care unit but still have medical indications for supplementation. Our institution is a hospital within a hospital, the University of Iowa Children's Hospital within the University of Iowa Hospitals and Clinics, where 1,950 births occur annually.
The Mother's Milk Bank of Iowa, founded in 2002, joined the University of Iowa Department of Food and Nutrition Services in 2006. The milk bank screens donors based on Human Milk Banking Association of North America (HMBANA) guidelines. Prospective donors complete a lifestyle questionnaire, and their blood is tested for human immunodeficiency virus 1 and 2, hepatitis B and C, human T-cell lymphotropic virus, and syphilis. Banked donor breastmilk is expressed by unpaid donors and frozen until delivery to the milk bank, where it is pasteurized by heating for 30 minutes at 62.5°C (Holder pasteurization). Milk from three to five donors is pooled to make a large volume, which is then separated into aliquots for pasteurization. 11 Pasteurization kills bacteria and white blood cells that may be found in milk, and the combination of heating followed by freezing inactivates viruses, including human immunodeficiency virus and cytomegalovirus.12,13 Pasteurization decreases levels of some infection-fighting and immune-stimulating factors in human milk, kills the milk leukocytes, decreases secretory immunoglobulin A levels by up to 40%, and decreases lactoferrin levels by 57%. 13 However, the alternative to pasteurized donor milk—infant formula—contains none of these infection-fighting compounds. For infants who have a medical indication for supplementation, such as excessive neonatal weight loss or hypoglycemia, donor milk is, therefore, the supplement of choice.
The Mother's Milk Bank of Iowa provides pasteurized donor breastmilk to the University of Iowa neonatal intensive care and well nurseries as well as 27 other hospitals: 10 within Iowa and 17 in other states. Per HMBANA's recommendations, individual hospitals decide whether to purchase milk from HMBANA banks, and each hospital may establish its own protocol for which patients are eligible to receive donor milk. The Mother's Milk Bank of Iowa has 20 collection depots in Iowa and adjacent states, and its supply surpasses the demand from participating hospitals. This allows the bank, in keeping with HMBANA guidelines, to fill outpatient prescriptions on an as-needed basis and to provide milk for research studies accepted by HMBANA's Research Committee. For outpatients, the University of Iowa's employee insurance covers 80% of the cost of donor breastmilk with a 20% copay paid by parents ($3 per 100-mL bottle). Other insurers have covered donor milk from the Mother's Milk Bank of Iowa for outpatients on a case-by-case basis but do not routinely offer coverage.
There are currently 16 HMBANA milk banks in the United States and Canada and several others under development, but, as noted previously, availability of banked donor milk is heterogeneous. In 2012, demand was 2,500,000 ounces, which was up 67% over the demand in 2009. 14 Supply has increased steadily over the last 15 years, but the demand for this product by hospitals only reflects those hospitals willing to pay to provide donor milk, as they are often not reimbursed for this expense.14,15 For-profit milk banks, researchers engineering human milk-based formulas and fortifiers, and individual consumers on unregulated Internet Web sites also all compete with not-for-profit HMBANA milk banks for donor milk, fueling an ongoing discussion regarding the ethics of providing compensation for human milk donors.15,16
The University of Iowa Children's Hospital has an 8-year experience offering donor breastmilk supplementation for term and late-preterm infants in the mother baby care unit/well newborn nursery, and it is our experience that breastfeeding mothers of term and late-preterm infants cared for in the well newborn unit are receptive to and accepting of donor milk as a supplement when it is recommended to them. Our nursing, physician, and lactation staff share a philosophy that it is every infant's right to be fed exclusively breastmilk, although we respect that there are certain cultural and religious barriers to universal supplementation with banked donor milk, and whether to use donor milk or formula is ultimately the parents' choice. Our hospital administration has supported continued availability of pasteurized donor breastmilk for use in any and all of our inpatient infant populations, so we are able to provide parents with the choice. Individual units are billed by the milk bank for donor milk they use each month, and unit nurse managers allocate a portion of their unit nutrition budget funds for this expense. The mother baby unit, which admits 1,200 newborn infants annually, spends an estimated $1,000–$2,000 per month for donor breastmilk.
There is a need for outcomes research in the population of term and late-preterm infants who receive donor breastmilk rather than formula, in order to provide an evidence basis for supplementation recommendations by the AAP and ABM. Additionally, research must continue to study the effects of donor milk supplementation in a variety of infant populations in order to provide an evidence basis to guide the decisions of healthcare providers, hospitals, and insurers as well as to help inform the equitable allocation of this precious resource.
Footnotes
Acknowledgments
We would like to thank The Mother's Milk Bank of Iowa, its co-founder and director Jean Drulis, BA, co-founder Ekhard Ziegler, MD, and the University of Iowa Mother Baby Care Unit/Newborn Nursery for their dedication to providing breastmilk to all babies.
Disclosure Statement
No competing financial interests exist.