Donor Human Milk Banking: Growth, Challenges, and the Role of HMBANA
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Donor Human Milk Banking: Growth, Challenges, and the Role of HMBANA Kimberly Horton Updegrove 1,2 N onprofit donor milk banks affiliated with HMBANA—the Human Milk Banking Association of North America—are dedicated to providing safe, pasteurized breastmilk to feed very low birth weight and other at-risk infants whose mothers cannot produce an adequate supply. In addition to setting standards for and accrediting member banks, HMBANA also facilitates formation of new banks and advocates for breastfeeding, appropriate use of donor human milk, and research to enhance donor milk’s effect on infant survival rates, growth, and development. Recent policy statements of the U.S. Surgeon General and the American Academy of Pediatrics strongly support HMBANA’s mission: Action 12: Identify and address obstacles to greater avail- ability of safe banked donor milk for fragile infants —Actions to Improve Breastfeeding, The Surgeon General’s ‘‘Call to Action to Support Breastfeeding,’’ 1 2011 The potent benefits of human milk are such that all preterm infants should receive human milk. Mother’s own milk, fresh or frozen, should be the primary diet, and it should be fortified appropriately for the infant born weighing less than 1.5 kg. If mother’s own milk is unavailable despite significant lactation support, pasteurized donor milk should be used. Quality control of pasteurized donor milk is important and should be monitored. —‘‘Breastfeeding and the Use of Human Milk,’’ 2 American Academy of Pediatrics, 2012 HMBANA milk banks receive milk expressed, frozen, and donated by unpaid, screened, and approved lactating wo- men, process it via the Holder pasteurization method, and dispense it to meet the specific medical needs of infants for whom it is prescribed. Some banks operate remote depots to provide additional local facilities to accept the milk, and some make provision to accept milk from remote locations shipped with dry ice. All member banks operate according to the or- ganization’s strict guidelines, updated annually. 3 Over 70% of the processed donor milk is dispensed to hospital neonatal intensive care units, primarily for treatment of severely low birth weight infants, who are at high risk for bloodstream infections, necrotizing enterocolitis, and feeding intolerances. Although mother’s own milk is preferred, many mothers of premature infants are unable to provide an ade- quate supply of expressed milk, and, of course, breastfeeding is difficult or impossible with the very preterm. Donor milk is prescribed also for outpatient infants with such diagnoses as formula intolerance, feeding difficulties, malabsorption, fail- ure to thrive, and congenital anomalies. Currently 16 HMBANA banks operate in the United States and Canada, with several more under development or at various exploratory and planning stages (Fig. 1). Some HMBANA banks are established as independent, nonprofit organizations with their own boards of directors; others function as departments within hospitals or medical centers. HMBANA banks dispensed nearly 2,500,000 ounces of pro- cessed milk in 2012, an increase of 67% over 2009 (Fig. 2). Growth in the number of milk banks, the amount of donor milk dispensed, and the number of hospitals and outpatients served are testimony to the increasing recognition by health- care providers and parents of the value of safe donor human milk. 4 HMBANA milk banks nevertheless face several chal- lenges 5 : Demand outstrips supply. Growing numbers of hospitals are placing orders for donor human milk as research determines that, compared with formula, donor milk improves feeding tolerances, decreases sepsis and nec- rotizing enterocolitis rates, and reduces rates of re- hospitalizations. Outreach and advocacy by member banks and HMBANA also contribute to growing un- derstanding of and requests for donor milk. Supply is limited, however, by suboptimal breastfeeding rates and a lack of awareness of milk banking and its benefits. Informal sharing diverts some donor milk to less needy in- fants. Although no systematic data are available, it is evident that a substantial amount of donor milk is being shared informally or sold via Internet channels. This bypassing of milk banks presents two problems. First, recipient infants are put at risk when fed milk that has not been pasteurized and cultured from donors who have not passed screening tests. Anecdotal evidence indicates that some informal donors consider them- selves healthy, despite being turned away by milk banks because of medication or herbal product use, risky lifestyle, or medical history. And, notwithstanding HMBANA’s rigorous donor screening, each bank dis- cards some donor milk that fails bacteriological stan- dards for safe dispensing. 6 Second, donor milk shared 1 President, Human Milk Banking Association of North America, Fort Worth, Texas. 2 Executive Director, Mothers’ Milk Bank at Austin, Austin, Texas. BREASTFEEDING MEDICINE Volume 8, Number 5, 2013 ª Mary Ann Liebert, Inc. DOI: 10.1089/bfm.2013.0079 435
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Transcript of Donor Human Milk Banking: Growth, Challenges, and the Role of HMBANA
Donor Human Milk Banking:Growth, Challenges, and the Role of HMBANA
Kimberly Horton Updegrove1,2
Nonprofit donor milk banks affiliated withHMBANA—the Human Milk Banking Association of
North America—are dedicated to providing safe, pasteurizedbreastmilk to feed very low birth weight and other at-riskinfants whose mothers cannot produce an adequate supply.In addition to setting standards for and accrediting memberbanks, HMBANA also facilitates formation of new banks andadvocates for breastfeeding, appropriate use of donor humanmilk, and research to enhance donor milk’s effect on infantsurvival rates, growth, and development.
Recent policy statements of the U.S. Surgeon General andthe American Academy of Pediatrics strongly supportHMBANA’s mission:
Action 12: Identify and address obstacles to greater avail-ability of safe banked donor milk for fragile infants
—Actions to Improve Breastfeeding, The Surgeon General’s‘‘Call to Action to Support Breastfeeding,’’1 2011
The potent benefits of human milk are such that all preterminfants should receive human milk. Mother’s own milk, freshor frozen, should be the primary diet, and it should be fortifiedappropriately for the infant born weighing less than 1.5 kg. Ifmother’s own milk is unavailable despite significant lactationsupport, pasteurized donor milk should be used. Qualitycontrol of pasteurized donor milk is important and should bemonitored.
—‘‘Breastfeeding and the Use of Human Milk,’’2 AmericanAcademy of Pediatrics, 2012
HMBANA milk banks receive milk expressed, frozen, anddonated by unpaid, screened, and approved lactating wo-men, process it via the Holder pasteurization method, anddispense it to meet the specific medical needs of infants forwhom it is prescribed. Some banks operate remote depots toprovide additional local facilities to accept the milk, and somemake provision to accept milk from remote locations shippedwith dry ice. All member banks operate according to the or-ganization’s strict guidelines, updated annually.3
Over 70% of the processed donor milk is dispensed tohospital neonatal intensive care units, primarily for treatmentof severely low birth weight infants, who are at high risk forbloodstream infections, necrotizing enterocolitis, and feedingintolerances. Although mother’s own milk is preferred, manymothers of premature infants are unable to provide an ade-quate supply of expressed milk, and, of course, breastfeeding
is difficult or impossible with the very preterm. Donor milk isprescribed also for outpatient infants with such diagnoses asformula intolerance, feeding difficulties, malabsorption, fail-ure to thrive, and congenital anomalies.
Currently 16 HMBANA banks operate in the United Statesand Canada, with several more under development or atvarious exploratory and planning stages (Fig. 1). SomeHMBANA banks are established as independent, nonprofitorganizations with their own boards of directors; othersfunction as departments within hospitals or medical centers.HMBANA banks dispensed nearly 2,500,000 ounces of pro-cessed milk in 2012, an increase of 67% over 2009 (Fig. 2).
Growth in the number of milk banks, the amount of donormilk dispensed, and the number of hospitals and outpatientsserved are testimony to the increasing recognition by health-care providers and parents of the value of safe donor humanmilk.4 HMBANA milk banks nevertheless face several chal-lenges5:
� Demand outstrips supply. Growing numbers of hospitalsare placing orders for donor human milk as researchdetermines that, compared with formula, donor milkimproves feeding tolerances, decreases sepsis and nec-rotizing enterocolitis rates, and reduces rates of re-hospitalizations. Outreach and advocacy by memberbanks and HMBANA also contribute to growing un-derstanding of and requests for donor milk. Supply islimited, however, by suboptimal breastfeeding rates anda lack of awareness of milk banking and its benefits.
� Informal sharing diverts some donor milk to less needy in-fants. Although no systematic data are available, it isevident that a substantial amount of donor milk is beingshared informally or sold via Internet channels. Thisbypassing of milk banks presents two problems. First,recipient infants are put at risk when fed milk that hasnot been pasteurized and cultured from donors whohave not passed screening tests. Anecdotal evidenceindicates that some informal donors consider them-selves healthy, despite being turned away by milkbanks because of medication or herbal product use,risky lifestyle, or medical history. And, notwithstandingHMBANA’s rigorous donor screening, each bank dis-cards some donor milk that fails bacteriological stan-dards for safe dispensing.6 Second, donor milk shared
1President, Human Milk Banking Association of North America, Fort Worth, Texas.2Executive Director, Mothers’ Milk Bank at Austin, Austin, Texas.
BREASTFEEDING MEDICINEVolume 8, Number 5, 2013ª Mary Ann Liebert, Inc.DOI: 10.1089/bfm.2013.0079
435
informally or sold for feeding to healthy infants poten-tially deprives premature and at-risk infants of milkneeded to survive and thrive.
� Efforts to increase supply must not compromise safety.HMBANA’s commitment to meeting demand for safedonor human milk led in 2011 to formation of twocommittees of experts in the fields of microbiology andpharmaceuticals. Each committee reviews clinical datato determine screening and bacteriological standards fordonor human milk. Publication of a standard microbi-ology testing protocol for HMBANA milk banks in the2013 Guidelines for the Operation of a Donor Human MilkBank3 aims to ensure optimal testing and subsequentdispensing or discarding of milk. The medication com-mittee reviews data pertaining to the transferability ofpharmaceutical products and the potential subsequenteffect on the infant, leading to clear standards forscreening and approving milk donors.
� Variation in donated milk may affect health outcomes. Re-search conducted by the Mothers’ Milk Bank at Austin,TX, demonstrates significant variation in the macronu-trient levels of milk donated to a milk bank. Thesefindings have led a majority of HMBANA milk banks toincorporate nutritional analysis and labeling into theirprocesses. Although not an HMBANA requirement, perse, data on nutritional content provide important inputfor evaluation of infant outcomes.
� Hospital funding and insurance coverage are often inade-quate. The economic benefits of human milk comparedwith formula are now well documented. Despite thesereports and the costs to insurance carriers for inpatientneonatal care, many neonatal intensive care units re-main resistant to providing unit funds to cover donorhuman milk processing fees. Parents of outpatients facean even greater challenge as private insurers frequentlyrefuse to cover donor milk fees. Several HMBANA milk
FIG. 1. HMBANA milk bank locations in the United States and Canada: Calgary, AB, Canada; Vancouver, BC, Canada; SanJose, CA; Denver, CO; Indianapolis, IN; Coralville (Iowa City), IA; Kalamazoo, MI; Kansas City, MO; Newtonville (Boston),MA; Raleigh, NC; Columbus, OH; Austin, TX; and Fort Worth, TX, Oklahoma City, OK, Portland, OR, Toronto, ON, Canada,and other sites are in development (dark colored drops).
FIG. 2. Growth in amount of donor milk dispensed by HMBANA milk banks.
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banks maintain charitable care programs, funded bydonations, to provide financial assistance to outpatients’families who lack resources. It is not yet known howhealthcare reform will affect this situation.
HMBANA and its member banks are responding to thesechallenges through outreach and advocacy via traditional andsocial media channels, engagement in and support for re-search and development, and partnerships with providers,researchers, and other advocates, including the United StatesBreastfeeding Committee. HMBANA milk banks are in-creasingly recognized for their critical role in the infanthealthcare system.
Disclosure Statement
No competing financial interests exist.
References
1. Office of the Surgeon General, Centers for Disease Controland Prevention, Office on Women’s Health. The SurgeonGeneral’s Call to Action to Support Breastfeeding. Office of theSurgeon General, U.S. Department of Health and HumanServices, Washington, DC, 2011.
2. Section on Breastfeeding. Breastfeeding and the use of humanmilk. Pediatrics 2012;129:e827–e841.
3. Human Milk Banking Association of North America. Guide-lines for the Establishment and Operation of a Donor Human MilkBank. HMBANA, Fort Worth, TX, 2013.
4. Perrine C, Scanlon K. Prevalence of use of human milk inUS advanced care neonatal units. Pediatrics 2013;131:1066–1071.
5. Updegrove K. Nonprofit human milk banking in the UnitedStates. J Midwifery Women’s Health 2013;1–7. doi: 10.1111/j.1542-2011.2012.00267.x
6. Landers S, Updegrove K. Bacteriological screening of donorhuman milk before and after Holder pasteurization. BreastfeedMed 2010;5:117–121.
Address correspondence to:Kimberly Horton Updegrove, MSN, MPH
Executive DirectorMothers’ Milk Bank at Austin
2911 Medical Arts Street, Suite 12Austin, TX 78705
E-mail: [email protected]
DONOR HUMAN MILK BANKING 437
