Strengthening Systems to Ensure All Infants Receive Human Milk: Integrating Human Milk Banking into Newborn Care and Nutrition Programming

We share a vision—a world where all infants have access to human milk. But in a world where women give birth in a range of conditions, with diverse levels of neonatal care and in complex settings for breastfeeding, in settings with a multitude of competing priorities for family and the health system, achieving this vision is a challenge. Regardless, no matter the conditions, all neonates around the world have a right to receive optimal nutrition: mother's milk.

Despite enormous gains in infant mortality over the past decade, focus is still required during the neonatal period wherein we have seen a slower decline than postnatal mortality. This critical period accounts for ∼44% of less than five deaths, which is up from 37% in 1990. ¹ Every region of the world is experiencing an increase in the proportion of less than five deaths during the neonatal period. Prematurity is the leading cause of neonatal deaths, with 15 million babies born preterm each year, the majority in Africa and South Asia. ²

This is unacceptable given that 75% of newborn deaths could be prevented with feasible cost-effective care, including essential care during child birth and the postnatal period, antenatal steroid injections, Kangaroo Mother Care, and antibiotics to treat newborn infections. The Every Newborn Action Plan outlines breastfeeding as a key component of essential newborn care, together with a package of interventions including hygienic care, thermal control, and newborn resuscitation (if required). Breastfeeding is complex and requires a supportive environment, particularly in special situations such as the neonatal period with at-risk infants. Global indicators are in place to monitor early initiation of breastfeeding and exclusive breastfeeding primarily; however, in-depth indicators are lacking to accurately monitor the support provided for women and actual feeding practices in neonatal ward circumstances, with high risk, sick, and small preterm and low birth weight infants. Globally, less than half of all newborns are put to the breast within 1 hour. ³ Do we fully understand the reasons behind this? We must ask ourselves, globally, if both nutrition and newborn health are agenda priorities, are we meeting the need?

There has historically been a divide between newborn care and traditional nutrition programs, resulting in disparate policies, systems, and priorities. Focus on providing optimal nutrition for the newborn—and identifying barriers and facilitators to them receiving human milk—is lacking.

The challenge becomes more complex in situations where infants do not have access to their mother's own milk, such as if the mother is ill, recovering in a different location, or has died. Although current indicators do not currently track how many vulnerable infants do not have access to their own mother milk, anecdotal evidence from neonate ward observations around the world estimates that up to 40% of infants in a neonate intensive care unit (NICU) settings may not have access to their mother's milk, for the first hours or days or for a longer more significant period. For low birth weight and vulnerable infants, the World Health Organization recommends donor human milk as the next best option, before considering provision of formula. ⁴ Donor human milk has been shown to be superior to infant formula for reducing incidence of necrotizing enterocolitis, sepsis, improving feeding tolerance, and reducing length of stay in an NICU setting.^5–11

Saving baby's lives through provision of donated human milk is an ancient practice. Wet-nursing and informal sharing have occurred through centuries. Yet for vulnerable infants, the rigorous human milk bank system, for screening, pasteurizing, storage, and distribution, is required to ensure safety of donor human milk. Yet, human milk banks, if implemented correctly, can serve a broader purpose as a key piece of protecting, promoting, and supporting breastfeeding. An integrated system is needed with focus on increasing access and intake of human milk in a comprehensive approach—through breastfeeding, Kangaroo Mother Care, and provision of safe donor human milk, when needed. ¹² Data have shown that if implemented in this way, with emphasis on an overall culture of valuing human milk, the presence of a human milk bank is associated with increased rates of breastfeeding at discharge. ¹³ Human milk banking should be embedded within, not separate from, breastfeeding promotion programs. By implementing programs in this way, donor human milk is used in situations only to replace infant formula; it should not replace mother's own milk, which remains superior in every way. Systems should be established with focus on the mother–baby dyad and ensuring that if a mother has the ability to produce milk, the system enables the milk to reach the infant—even if a mother is recovering and the infant is in a separate specialized ward.

With ∼600 human milk banks operating around the world, the numbers are increasing. In the United States, in 2008 there were 10 operational human milk banks, growing to 27 operational and 4 developing banks in 2018. ¹⁴ Regional associations have been developed in North America, Europe, South Africa, and India to develop guidelines and standards for safety and implementation. The National Network of Human Milk Banks in Brazil is considered a global model: with >250 human milk banks in the country and established as an integrated system for supporting women to breastfeed as well as to donate. ¹⁵ Yet the number of human milk banks remains critically low and is inadequate to meet the demand for providing donor human milk to offset formula use for vulnerable neonates.

Effective expansion of human milk banks has been limited due to a number of factors. First, there are currently no global guidelines or standards on safe collection, processing, or distribution of donor human milk. Similar to global standards that have been developed on blood and tissue safety, guidance to ensure safety of donor human milk is needed. Currently, governments or hospitals must develop guidelines and standard operating procedures in the absence of a standard, resulting in a range of practices and quality. Second, polices aligning newborn care and nutrition strategies to prioritize access to and use of human milk for vulnerable neonates have been lacking. Third, there is lack of routinely collected data to accurately document practices in NICU settings related to supporting mothers to breastfeed or provide their expressed milk, as well as how vulnerable infants are being fed. It is unknown how many infants around the world lack mother's own milk for any period during an NICU stay, how often mother's milk is shared informally, and what the true need for donor human milk is. Fourth, most human milk banks have been limited by systems and programs; they have been established as independent facilities only for collection, processing, and storing human milk, rather than as a linked integrated component of a national or facility-based breastfeeding promotion program. Fifth, operating a human milk bank requires infrastructure and equipment for pasteurizing, screening, and storing. Innovation is needed to develop simplified systems at lower cost to ensure feasibility for low-resource settings to achieve the same safety and quality. In addition, innovation is needed to develop new systems for pasteurization or alternative treatments for ensuring safety of donor human milk while not compromising quality.

PATH has been working with newborn, nutrition, and human milk bank leaders to address these gaps through developing resources to guide an integrated, safe, and quality controlled system.^16,17 A phased approach has been used to build capacity, integrate nutrition, newborn systems, and increase rigor to demonstrate impact, working closely with local stakeholders and governments, in South Africa, India, Vietnam, and currently in Kenya. Phases of this approach include (1) establishing local ownership and technical competency, through developing learning exchanges, conducting formative assessments, and developing country-specific strategies and guidance; (2) operationalizing through conducting breastfeeding promotion and establishing human milk bank quality control systems; and (3) research and evaluation through rigorous monitoring and data to document impact and ensure sustainable expansion. Results to date have been promising, demonstrating that implementing a holistic approach to newborn nutrition is feasible and can be effective to increase overall intake of human milk, through improved breastfeeding practices and provision of safe donor human milk.

If we are to achieve the vision of ensuring that all infants—including those in NICU settings—receive human milk, then a transformation of the field of newborn nutrition is urgently needed. A coordinated effort by technical and policy and technical leaders across both newborn care and nutrition fields is required as outlined as follows:

Commit to developing, improving, and enforcing policies and legislation that protect, promote, and support breastfeeding for all infants, including exclusive human milk feeding for sick and vulnerable newborns, through strengthening systems for comprehensive lactation support in critical care facilities. ¹⁸

Strengthen data tracking systems for inclusion of human milk use within indicators for early initiation of breastfeeding.

Invest in training and capacity building in the optimal feeding of premature, sick, and vulnerable newborns.

Integrate the provision of donor human milk from human milk banks into national strategies and policies as part of a comprehensive approach for essential newborn care and improving breastfeeding, infant and child feeding, and nutrition.

Establish culturally appropriate national standards, guidelines, and systems for establishing human milk banks, monitoring distribution and quality control of donor human milk, and ensuring equitable access to donor human milk.

Ensure that policies and programs to increase access to and intake of donor human milk do not undermine breastfeeding but are part of a comprehensive strategy to ensure optimal feeding of sick and vulnerable newborns.