In recent decades, remarkable technologies have been developed to save and improve the lives of high-risk infants. Yet one of the biggest “advances” that has been shown to save lives and decrease morbidity is the use of human milk as a primary source of nutrition for very low birthweight (VLBW) infants.
With strong evidence supporting a marked decreased risk of necrotizing enterocolitis and emerging evidence about lower rates of other conditions including bronchopulmonary dysplasia, it has become crucial to determine how to ensure that VLBW infants receive a primary human milk-based diet. A mother’s own milk is preferred but, because many mothers cannot produce enough milk for their infants, it is necessary to provide donated human milk to many infants.
The AAP Committee on Nutrition, the Section on Breastfeeding and the Committee on Fetus and Newborn have issued a policy statement supporting the use of pasteurized donor human milk in VLBW infants, with consideration of its use in other high-risk infants such as those with intestinal failure.
However, the cost and availability of adequate supplies of donor milk are major impediments to its broader use in the United States, according to
Donor Human Milk for the High-Risk Infant: Preparation, Safety and Usage Options in the U.S. The policy is available at http://dx.doi.org/10.1542/peds.2016-3440 and will be published in the January issue of Pediatrics.
Overcoming impediments
Because of limitations related to availability and cost, some families choose to feed their infants milk provided or sold to them that hasn’t been screened or pasteurized by a recognized human milk bank. The policy notes that this “direct milk sharing” approach has a risk of viral or other disease transmission and is not recommended. However, the policy further indicates that cost should not be an impediment to providing the life-saving benefits of pasteurized, safely obtained and screened human milk, especially for VLBW infants.
Pediatricians and other care providers should discuss with families of high-risk infants the high level of safety of donated human milk, the importance of trying to provide as much maternal milk as possible and the tremendous benefits of human milk. They should advocate for reimbursement policies supporting increased availability of donor milk.
Technology remains a critical aspect of modern neonatal care, and technological improvements to support the banking, pasteurization and delivery of donor human milk are important goals. Methods to decrease the loss of immunologically important human milk components need to be improved.
Above all, in the haste to adopt and spend money on technological devices, testing and interventions, funding should be readily available and support services in place to provide the most basic, and perhaps the most powerful of interventions for VLBW infants — safely obtained human milk for feeding.
Key points
- Donor human milk may be used for high-risk infants when the mother’s milk is not available or sufficient. Priority should be given to infants weighing less than 1,500 grams at birth.
- Donors should be identified and screened with methods such as those used by the Human Milk Banking Association of North America (see resources) or other established commercial milk banks.
- Donor milk should be pasteurized according to accepted standards. Postpasteurization testing should be performed using internal quality control guidelines.
- Families should be discouraged from direct human milk sharing or purchasing from the internet because of the increased risks of bacterial or viral contamination of nonpasteurized milk and the potential exposure to medications, drugs or other substances, including cow’s milk protein.
- The use of donor human milk in high-risk infants should not be limited by an individual’s ability to pay. Policies are needed to provide these infants access to donor human milk on the basis of documented medical necessity, not financial status.
Dr. Abrams, a lead author of the policy, is a former member of the AAP Committee on Nutrition.
