Milk kinship is an Islamic belief that human milk creates a kinship between the breastfeeding woman and her nonbiological nursing infant (as well as the woman’s biological nursing infants) prohibiting future marriages between “milk brothers and sisters.” As such, Muslim families in the Western world may be reluctant to use donor human milk from human milk banks given the anonymity and multiplicity of donors. Health care providers for the mother-newborn dyad should be aware of this belief to have respectful, informed conversations with Muslim families and appropriately advocate for healthy newborn feeding. With this article, we outline the basis of milk kinship in Islamic beliefs, explore religious and bioethical interpretations of milk kinship, and provide information for physicians and other health care workers to become more knowledgeable about this practice.
Islam is the world’s second largest and fastest-growing religion, with an estimated 3.45 million Muslims living in the United States alone.1 Physicians will undoubtedly encounter Muslim patients in their practice and should develop a working knowledge and understanding of Islamic beliefs related to health. As physicians whose patient populations frequently involve the whole family, pediatricians have a unique obligation to acknowledge the influence of Islamic faith on health practices that parents may wish to adhere by for their children. Within Islam, there exists a range of cultural beliefs and religious interpretations. These differences are attributable to varied opinions by different schools of Islamic jurisprudence, as well as different geographic and ethnic traditions.2 Islam contains a moral code and civil law that may at times diverge from US secular practices. Pediatricians would therefore benefit from learning about Islamic beliefs to develop an awareness that will help them best support Muslim families with a shared goal of promoting healthy infant growth and development. Additionally, by gaining an understanding of Islamic values and beliefs, pediatricians can establish rapport centered on respect and equip themselves to provide culturally sensitive care for their Muslim patient populations.
This document is meant to serve as a guideline for medical teams involved in the health care of Muslim families and their newborns. Specifically, we examine Islamic religious teachings regarding breastfeeding and milk kinship (which we will discuss further). We discuss recommendations for the use of donor human milk (DHM) in a shared decision-making process with Muslim families living in the Western world. An understanding of these topics is likely to benefit all team members of the mother-newborn dyad, including pediatricians, neonatologists, obstetrician-gynecologists, nurses, and lactation specialists.
Breastfeeding and Milk Kinship
Breast milk is considered the optimal nutritional source for infants by health and medical organizations. Both the World Health Organization and American Academy of Pediatrics recommend DHM as the second best alternative when a mother’s own breast milk is unavailable or in short supply.3 DHM has notable health benefits for sick and preterm infants in NICUs. These include reductions in the incidence of necrotizing enterocolitis, sepsis, and bronchopulmonary dysplasia, as well as enhanced feeding tolerance and greater neurodevelopmental outcomes.4–6 As such, health care teams carry a responsibility to promote and support breastfeeding to potentially address inequalities in neonatal and pediatric health.4
The Qur’an is the only religious text of the Abrahamic religions that details a position on breastfeeding. In verse 46:15, the Qur’an references a physiologic bond between a mother and child lasting 30 months.7 This has been interpreted as a period that starts during gestation and continues until weaning when the child is ∼2 years old. Although initially sustained by intrauterine blood, this relationship is maintained after birth by human milk. In essence, breastfeeding serves as the postnatal extension of the intrauterine period of pregnancy and may be continued for 24 months for those who wish to complete this term. This time line aligns with recommendations from the World Health Organization in which breastfeeding is recommended up to the age of 2 years or beyond.8
In verse 2:233, the Qur’an also indicates that if the mother is unable to or does not wish to provide milk, a wet nurse could be selected for her child.9 This is common practice in Islamic culture and dates as far back as the Prophet Muhammad being nursed by wet nurses from Bedouin tribes. In Muslim countries today, the “wet nurse” may be a relative or family friend known to the recipient infant’s family.3 However, Muslim women in the Western world often do not have the same social structure and familial support commonly experienced in Muslim countries.3,7,10 As a result, access to known donor mothers is not the same, and the use of DHM from human milk banks (HMBs) for medically fragile infants may be brought into consideration.
However, religious and cultural beliefs within Islam may pose a barrier to using human donor milk. This includes “milk kinship,” the belief that donor breast milk establishes a relationship between the donor mother (along with her own offspring) and the donor milk recipient.11 The Qur’an states, “Prohibited to you [for marriage] are…your milk mothers who nursed you and your sisters through nursing…” (Nisa 4:23).12 This is the basis of rida’a, the kinship established via milk between a child and the woman who nursed the child. Milk kinship applies to the children of the donor mother as well because they are now considered “milk siblings” with the infant receiving the milk.11 The relationship generated by nursing is similar to the relationship generated by blood (nasab) and bars marriage in Islamic law. When using DHM, a Muslim family may have reservations about their child unknowingly marrying one of his milk relatives. To avoid inadvertent or unintended marriage that may occur in situations when donors are anonymous, the donor mother and recipient families should be known to each other.
However, Western HMBs pool milk from several donors.3 Because milk is not identifiable to a single donor or tracked to recipients, there is no way to truly know where donor milk comes from and where it goes. The anonymity of donors might cause Muslim families to be concerned about crossing lineages and create reservations about using or donating DHM.3,13 Milk kinship is both a religious and cultural belief. Although referenced in the Qur’an, its interpretation largely depends on the family’s origin and culture.12,13 Health care workers should sensitively discuss this with families with a goal of considering all options for the newborn and encouraging the family to discuss the use of DHM with their religious advisors. Although health care workers can make clear that breast milk is the best food to optimize infant health, their ultimate role is to empower families to take information and work out their personal practices with those they trust in their religious communities.
As noted above, the different schools of jurisprudence in Islam have distinctions in their interpretation of Islamic law. When Islamic jurisprudence is unclear, legal councils may gather to deliberate and issue a fatwa.14 Fatwas are religious rulings on a point of Islamic law issued by a recognized authority, such as a qualified Islamic legal scholar. Modern fatwas have increasingly reflected the changing social and biomedical concerns of Muslim communities.
With a rapidly increasing number of Muslims living in the Western world, as well as the increase in HMBs over the 20th century, Muslim scholars recognized the importance of issuing rulings on HMBs.11,12 Historically, there have been differences of opinion from jurists and scholars on this issue. In 1983, the Islamic Organization for Medical Sciences in Kuwait held a session on Islam and human reproduction.10 At the time, many jurists opposed the establishment of milk banks in the Muslim world because the anonymity of pooled donor milk was considered problematic under the principle of milk kinship. The 1983 session did, however, provide strict conditions under which donor milk could be used. Stipulations included that the name of the donor should be documented on each milk bottle, and a detailed registry should document the donor woman and all recipients of her milk. This information was to be shared between donor and recipient families to avoid marriage between members of these families. Additionally, although the minority opinion at the session, approval of milk banks was expressed even in 1983. Advocates cited HMBs as a noble aim under the third pillar of Islam, charity, and the provision of human milk to a preterm infant in need as a moral imperative.10,15
In a pioneer study from 2012, Mohammed Ghaly,10 professor of Islam and biomedical ethics at the Research Center for Islamic Legislation and Ethics at Hamad Bin Khalifa University in Qatar, examined the fatwas addressing milk kinship within 2 contexts: the Muslim world, as well as Muslim minorities living in the West. He pointed out the continued relevance of milk kinship in the daily lives of modern Muslim families and examined the conflicting views on accepting donor milk for Muslim infants.
Ghaly10 reported that in 2004, the European Council for Fatwa and Research (ECFR), a foundation created in 1997 to specifically address issues pertinent to Muslims living in the West, recognized the position of “Muslim minorities living in a non-Muslim context” and addressed the use of milk banks among these communities. In the study, Ghaly10 states the ECFR came to the conclusion that the use of milk banks does not raise religious issue in Islam given the following:
Milk banks continued to increase in number across the Western world and were a common reality Muslim minorities in the West would face.
There is an absence of identified or “known” wet nurses in the Western world compared to in the social structure of the Muslim world.
Milk banks underwent rigorous procedures to ensure medical safety and eliminate risk of disease transmission.
Milk banks in the West contain an element of doubt (shakk) because, at present, they do not keep a detailed registry of donating women, recipient infants, or proportions of milk mixed in banks.
Although the concept of milk kinship is well known, this most recent fatwa from 2004 may not be familiar to or universally accepted by Muslim families.11,13 Fatwas provide Muslims with religious and bioethical guidelines. These religious rulings are supposed to be derived on the basis of context and may vary depending on specific circumstance. There are differences of opinion as to if or when these types of religious rulings are binding because they are a matter of scholarly interpretation and opinion.14 Ultimately, “binding” refers to the fidelity with which Muslims themselves may adhere to the recommendations, as there is no external enforceability. Instead, Muslims follow the rulings to act virtuously and avoid sin. Depending on which scholarly opinion Muslim families follow, they may have differing beliefs about the use of pooled DHM. The text of the final statements of the 2004 ECFR fatwa on HMBs (Supplemental Information) can be found on their Web site (https://www.e-cfr.org/blog/2017/11/04/twelfth-ordinary-session-european-council-fatwa-research/).16 Muslim families can use this resource to learn more about the ruling, seek out more information, and discuss with their religious advisors whether they would follow this fatwa.
Milk Kinship and Epigenetics
Restrictions on milk kinship may be based on concern for potential transmission of genetic material in breast milk3,17,18 In their article, “Milk Kinship Hypothesis in Light of Epigenetic Knowledge,” Ozkan et al18 postulate that substances affecting epigenetic regulation can be passed down through breastfeeding. He states breast milk contains genetic material, such as microRNAs and stem cells, which can modify expression of certain genes leading to consanguinity and increased genetic disease. However, this argument is not supported by the known processes of consanguinity and genetic disease. Consanguinity requires 2 copies of a mutated gene to be inherited by an affected person to result in an autosomal recessive genetic disease.12 Additionally, studies have revealed breast milk is digested, and genetic substances in human milk, like microRNA, are broken down by the gastrointestinal tract. Donor milk undergoes additional harsh storage processes such as freeze-thaw cycles, incubation in acidic solutions, or high temperatures of pasteurization, which degrade microRNA found in human milk.15 Intact genetic material is not passed onto the recipient infant and so there is no mechanism responsible for an autosomal recessive disorder through breast milk.12 By explaining these processes to reluctant parents, health care workers may alleviate concerns about the increased risk of genetic or consanguineous disease from an unknown donor.
Donor Milk Recommendations
To our knowledge, there are no HMBs currently operating in any Muslim country primarily because of religious and cultural concerns. Although the Turkish Ministry of Health began the process of establishing a non–Western-style milk bank, the project was ultimately withdrawn because of protests stemming from the public perception of Western-style HMBs.3 Similarly, there are no milk banks we are aware of that address the religious concerns of Muslim families in the United States.
However, a recent empirical study revealed that >70% of Muslim scholars would be open to the development of a milk bank if religious considerations were addressed.19 In another study in Turkey, authors similarly reported that a majority of mothers had a more positive response to donating and using donated milk if religious concerns were relieved.3 Because the issue of using DHM seems to be founded on the uncertainty of identity, the use of human donor milk for Muslims living in the Western world should be centered on donor and recipient identification. As stated in the 1983 fatwa on milk banks, there are strict conditions under which DHM can be used.
There may be instances in which donor milk is appropriate if the donor and recipient are identified to each other and the milk used was limited to a small number of donors. Specifically, if the family agrees to use donor milk under these conditions, efforts should be made toward practices such as writing the name of the known donor on each bottle, creating a detailed record, and making sure both donor and recipient families have access to this information. In their article on the feasibility of religiously compliant donor milk sharing, Alnakshabandi and Fiester20 add the recommendation of capping the number of donors pooled together at 3 to 5 to limit marriage restrictions.
Additionally, health care workers should be mindful of the availability of other sources of breast milk, such as a family member, friend, or someone else known to the family that they may prefer as an arranged donor instead.13 Small-scale milk-sharing programs have been attempted in Kuwait and Malaysia in which the recipient and donor parties meet, discuss religious implications, and complete consent forms.20 By being thorough and intentional about identification, religiously compliant alternatives to milk banking may be available to Muslim families.
In his 2012 study, Ghaly10 recounts a Muslim couple in Oxford, England, who persistently refused DHM for their premature child to the confusion of hospital staff, only finally understood when a midwife heard about milk kinship and reservations about potential incest. This anecdote reveals the need for health care workers to understand the religious basis of reluctance toward DHM among Muslim families living in the West. There may be opportunities to have open discussions and answer all questions about DHM while educating and empowering Muslim families to navigate the nuances of their personal beliefs and practices. Milk kinship is a part of Islamic law, but its interpretations depend on the context of the family. Once the health care worker has shared his or her knowledge, families can consult with their religious advisors. Additionally, health care workers can be proactive in exploring suitable alternatives to milk banking available locally for these families. With this awareness, health care workers can engage in a more informed shared decision-making process with their Muslim patients.
Although some aspects of Islam appear divergent with US standards of newborn care, it is imperative for health care workers involved with the mother-infant dyad to become familiar with and understand the rationale behind these beliefs to establish a relationship built on rapport and trust. Pediatricians bear responsibility in sharing the known health benefits of breast milk with parents of premature and newborn infants, but helping families adopt optimal infant feeding practices requires an understanding of their perspectives on breastfeeding and donor milk.
We thank Dr Sahira Humadi for providing personal and religious context, as well as her review of the article.
Drs Sriraman and Subudhi conceptualized the study, drafted the initial manuscript, and reviewed and revised the manuscript; and both authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.