Written by : Hillary Kuzdeba, MPH
Many women in developed countries like the U.S. find that despite their best efforts, they are unable to exclusively breastfeed due to supply problems or other circumstances. They may feel pressured into finding some other way of ensuring their babies are exclusively breastfed, even though they cannot produce enough for baby. Adoptive parents may also feel pressure to provide breast milk. A lot of this pressure to provide breast milk comes from the over-exaggeration or misinterpretation of the benefits of breast milk on long term health outcomes, or from unfounded fears about infant formula.
Currently there are two types of donor breast milk available to moms in the US, but only one type that is supported and recommended by major medical bodies like the American Academy of Pediatrics (AAP)(1, 2) and by the Fed is Best Foundation. Donor milk obtained from a milk bank or hospital is a safe and healthy alternative to mom’s own milk.(2) Milk banks thoroughly screen their donor moms to ensure the safety of the milk and pasteurize it following strict food safety protocols to destroy bacteria that can make infants very ill. Milk banks are similar to blood banks. These organizations are designed to make sure human body fluids, whether breast milk or blood products, are screened and safe before they are used by vulnerable people like newborns and sick patients. This is because human body fluids, including breast milk, can pass transmissible infections like HIV from person to person.(3-5) For more information on the milk bank process, please visit https://www.hmbana.org/.
Unfortunately due to their rigorous safety procedures and the costly and time intensive effort of screening and pasteurizing the donor breast milk, the majority of moms in the US do not have access to safe, screened donor milk through a milk bank. Currently, there are only 24 operating milk banks in North America.(2) Most screened and pasteurized breast milk is reserved for preterm and hospitalized infants, and so it is not common for milk banks to have substantial reserves left over for the public. The reimbursement cost to hospitals and families who use donor breast milk obtained through a milk bank can be very expensive due to the operating expenses of maintaining the milk bank.(6)
While breast milk from a milk bank is a safe and healthy food source, it is unlikely to be viable option for most families due to limited availability and cost. For those families that are fortunate enough to have access to screened milk through a milk bank and also have the financial resources to support the ongoing expense, they may decide that choosing this nutrition source is their preference over infant formula. These parents should however be aware of the variable nature of donor milk supplies, and they should be prepared for the possibility that they will need to use formula at some point due to milk banks’ varying reserves of donor milk.
Due to the lack of safe donor milk provided by milk banks and hospitals, some parents are turning to unscreened peer-to-peer milk donations or sales facilitated over the internet. This is the second type of donor milk that is available. The AAP and the Fed is Best Foundation do NOT recommend that parents feed their children peer to peer milk obtained through informal donations, sales, or milk sharing websites. This is because there are growing safety concerns posed by offering unscreened and unregulated breast milk to infants. Parents should not confuse the general breastfeeding guidelines put forward by organizations like the WHO and AAP with a tacit endorsement of peer to peer donor milk sharing in countries like the US – they are not. To date, the AAP explicitly discourages feeding infants unscreened peer to peer donor milk purchased or obtained via informal donations over the internet.(1-2) Currently, no major medical organization endorses, encourages, or recommends the practice of sharing unscreened breast milk in developed nations where safe infant formula is available.
Safety Concerns Surrounding Peer to Peer Milk Donation & Sales
Both peer to peer donations, as well as for-profit breast milk sales over the internet have been found to raise serious safety concerns. Research has demonstrated that some milk banks are still seeing significant incidence of potential donor moms with positive blood tests for conditions including HIV, syphilis, and hepatitis.(7) Without access to rigorous screening services, a small but significant percentage of infected mothers are at risk of sharing their breast milk with other families over informal milk sharing websites. In addition, recreational drugs, herbal supplements, and various prescription medications have all been found to be present in breast milk, and some of these substances have potential adverse effects.(8) In a milk bank or hospital, many of these substances, including popular herbal remedies for milk supply, disqualify a mother from donation. The milk banks can ensure their milk is free of various substances, but due to the very high prevalence of recreational and prescription drug usage in the general public, breast milk containing elements of numerous drugs is inevitably circulating in informal milk sharing networks. Given the highly publicized and optimistic assertions about various herbal remedies for milk supply, it is also likely that herbal supplement usage in particular may be high amongst informal donations.
In terms of food safety, a 2017 study on peer-to-peer donors discovered that while the majority of informal donors did make an admirable and conscious effort to handle and store their milk appropriately, the majority of them still did not follow at least 4 of the 5 food safety and handling steps necessary to ensure the safety of their donations.(9) Furthermore, a recent article published by clinicians at a pediatric hospital explored two cases of medically complex infants who were subsequently found to be using unscreened, unpasteurized peer to peer donated breast milk obtained by their parents.(10) These cases suggest that even highly vulnerable, medically fragile infants may also be experiencing exposure to unscreened and unpasteurized breast milk from unknown sources, potentially without their clinical team’s knowledge. Sadly, the devastating effects of bacterially contaminated breast milk came into sharp focus recently in 2016, when a preterm infant contracted a severe chronobacter infection, causing developmental delays. The infection was believed to be caused by contamination of the mother’s breast pump and the surrounding area used to clean the pump parts.(11, 12) The baby This case verified that contaminated breast milk can have tragic consequences for vulnerable newborns and their families.
The data on for-profit breast milk sales is also concerning. A study published in Pediatrics in 2013 found that a whopping 75% of the milk samples purchased over the internet were contaminated with bacteria.(13) A follow up study in 2015 found that approximately 10% of samples of breast milk sold over the internet were potentially watered down with cow’s milk.(14) Many peer to peer donation advocates claim that there is a significant difference between the “type” of people who sell milk and those who donate informally, and so the data on breast milk sales does not apply to them and their version of milk sharing. The implication here is that only “good” or “healthy” people informally donate and therefore their donations should be viewed as automatically safe, based predominantly on the perceived moral character of the donor. However, as we have seen, safety concerns still exist in the well intentioned informal donations, even without the presence of unscrupulous sellers looking to make a quick buck.
Peer-to-peer milk sharing websites and informal donor moms certainly have the best intentions, but even the most well-meaning donor mom can accidentally contaminate her milk with microscopic bacteria while handling it, and some moms with transmissible infections like HIV do not know they are infected. Furthermore, few members of the lay public have formal training in appropriate handling and storage of human body fluids to prevent contamination, leading to purely unintentional missteps in food safety procedures. Contaminated food sources can be dangerous for even full term healthy infants, and the risk is heightened for preterm or medically fragile infants who are already under substantial physiologic stress. Unfortunately, good intentions don’t make up for basic public health safety precautions.
Screened and pasteurized breast milk obtained through a legitimate source like a milk bank or hospital is a safe and potentially beneficial food source for infants – particularly the preterm population. However, this resource is currently very limited and most families will not have access to this nutrition source for their infants unless there is a documented medical need. While breast milk is wonderful, its potential benefits are not so important or so life defining that it is worth risking your child’s immediate safety by exposing them to breast milk obtained from questionable or unknown sources. If you live in a developed nation like the US, and you cannot produce enough milk or access a milk bank, the major medical organizations are clear – your safest and recommended infant feeding choice is commercially available infant formula.
- American Academy of Pediatrics. New American Academy of Pediatrics recommendations aim to ensure safe donor human milk available for high risk infants. https://www.aap.org/en-us/about-the-aap/aap-press-room/pages/New-American-Academy-of-Pediatrics-Recommendations-Aim-to-Ensure-Safe-Donor-Human-Milk-Available-for-High-Risk-Infants-Who.aspx. Accessed on: 7/28/2017.
- American Academy of Pediatrics. Donor human milk for the high-risk infant: preparation, safety, and usage options in the United States. Pediatrics. 2017; 139(1).
- UNAIDS. A review of HIV transmission through breastfeeding. http://www.unaids.org/sites/default/files/media_asset/jc180-hiv-infantfeeding-3_en_1.pdf. Accessed on: 7/28/2017.
- World Health Organization. HIV transmission through breastfeeding: A review of the evidence. http://www.who.int/nutrition/publications/HIV_IF_Transmission.pdf. Accessed on: 7/28/2017.
- John-Stewart G, Mbori-Ngacha D, Ekpini R, Janoff, EN, Nkengasong J, Read JS, Van de Perre P, Newell ML. Breastfeeding and transmission of HIV-1. J Acquir Immune Defic Syndr. 2004; 35(2): 196–202.
- Bar-Yam, N for Lactation Matters. Why is donor milk so expensive? https://lactationmatters.org/2013/11/08/why-is-donor-milk-so-expensive/. Accessed on: 7/28/2017.
- Cohen RS, Xiong SC, Sakamoto P. Retrospective review of serological testing of potential human milk donors. Arch Dis Child Fetal Neonatal Ed. 2010; 95(2): F118-20. doi: 10.1136/adc.2008.156471.
- American Academy of Pediatrics. The transfer of drugs and other chemicals into human milk. Pediatrics. 2001; 108(3). http://pediatrics.aappublications.org/content/108/3/776. Accessed on: 7/28/2017.
- Reyes-Foster BM, Carter SK, Hinojosa MS. Human milk handling and storage practices among peer milk-sharing mothers. J Hum Lact. 2017; 33(1): 173-180. doi: 10.1177/0890334416678830. Epub 2016 Dec 15.
- Barbas KH, Sussman-Karten K, Kamin D, Huh SY. Unpasteurized shared human milk use in pediatric inpatients: health and ethical implications. Hospital Pediatrics. 2017; 7(6).
- CBC News. Contaminated breast milk pump leaves preterm infant severely ill. http://www.cbc.ca/beta/news/health/breast-pump-cronobacter-1.4214341. Accessed on: 7/29/2017.
- Bowen A, Wiesenfeld HC, Kloesz JL, Pasculle AW, Nowalk AJ, Brink L, Elliot E, Martin H, Tarr CL. Notes from the Field: Cronobacter sakazakii Infection Associated with Feeding Extrinsically Contaminated Expressed Human Milk to a Premature Infant — Pennsylvania, 2016. CDC Morbidity and Mortality Weekly Report. 2017; 66(28);761–762. https://www.cdc.gov/mmwr/volumes/66/wr/mm6628a5.htm?s_cid=mm6628a5_w. Accessed on: 7/29/2017.
- Keim S, Hogan J, McNamara K, Gudimetla V, Dillon C, Kwiek J, Geraghty S. Microbial contamination of human milk purchased via the internet. Pediatrics. 2013; 132(5):e1227-35.Keim SA, Kulkarni MM, McNamara K, Geraghty SR, Billock RM, Ronau R, Hogan JS, Kwiek JJ.
- Cow’s Milk Contamination of Human Milk Purchased via the Internet. Pediatrics. 2015; 135(5):e1157-62. doi: 10.1542/peds.2014-3554. Epub 2015 Apr 6.
Hillary holds her Master’s degree in public health from Boston University. Her professional interests include women’s health, pediatrics, public health research, and quality and safety within the hospital setting. Over the years, Hillary has worked with vulnerable populations including women with HIV, active substance users, and resettled refugees in initiatives aimed at providing social support, access to care, and health behavior education and modification. More recently, she served as the program coordinator for a growing clinical research group in a pediatric hospital where she managed a high volume of research and quality improvement projects designed to measure and improve patient outcomes in critically ill children. In this role, she implemented projects that focused on monitoring infant feeding protocols and plans, and sat on a standing committee of hospital staff and researchers tasked with facilitating the measurement of quality of care across the organization. Hillary supports the Fed is Best Foundation because she is a mother who experienced breastfeeding difficulties and the emergency readmission of her newborn daughter for hyperbilirubinemia and dehydration. As a professional trained in both health promotion initiatives and quality improvement, she believes that the current exclusive breastfeeding protocols and advice utilized in many hospitals, and promoted by breastfeeding advocacy groups, are directly contributing to the clinical deterioration of a subset of exclusively breastfed infants. Hillary suspects that the Fed is Best approach to breastfeeding, which emphasizes baby’s safety, mother’s well-being, and an inclusive vision of successful breastfeeding, will soon be at the forefront of the ongoing public health conversation on breastfeeding, neonatal health, and postpartum care.
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