Interview conducted by April Cashin-Garbutt, BA Hons (Cantab)
Please could explain why breast milk is so important?
The available literature clearly demonstrates that in almost all circumstances a mother’s own breast milk is the ideal food for her infant. This is particularly important for preterm infants. Preterm infants are babies born before 37 completed weeks of pregnancy.
Breast milk contains a lot of maturational factors that mature the gut faster, making it easier for preterm infants to tolerate feeds. Breast milk also contains a lot of immunological factors that protect the vulnerable preterm gut from infection and inflammation. It has also been linked with better long term metabolic health and less obesity, so feeding babies with breast milk now is an investment in the future.
It is important to note that there is no evidence of benefit for donor human milk for term infants, although there is overwhelming evidence for breast milk in term infants. The evidence available for donor milk is for preterm infants only.
Why do some mothers of premature babies need access to breast milk?
Mothers of preterm babies do not always produce enough life sustaining breast milk for their infants, due to a variety of reasons, i.e. geographic (a preterm baby might be retrieved from another town or city), stress or social reasons.
This is usually an enormously stressful time for a mother. Parents must cope with constant worry about how their baby is responding to his or her treatment in a very unfamiliar and sometimes frightening environment.
To add to this, mothers are faced with the added pressure of trying to produce enough life saving breast milk for their baby, often when they are unwell with their own post-pregnancy or delivery complications. In an American study only 27% of mothers were able to sustain their lactation to meet their infants’ needs with mother’s own milk.
The only alternative is usually infant formula, which is risky in preterm infants. Formula use in preterm infants is associated with a higher incidence of hospital acquired infections, and also a 3-fold increase in a condition called necrotising enterocolitis (NEC). NEC is a devastating gut disorder in preterm infants that can result in 50% of babies dying, and 30% needing surgery. It significantly increases the time that babies spend in hospital. It is also associated with a poor neurodevelopmental outcome in survivors or prematurity. Mother’s own breast milk and donor breast milk has a protective effect on NEC.
Please could you give a brief introduction to breast milk banks?
Wet nursing dates back to 2000 BC. Milk banking was a common practise internationally since the 1900s. The first milk bank was established in Vienna in 1909. Each large maternity hospital in Australia had an informal milk bank, where excess milk from mothers was pooled and given to those who needed it.
With the advent of HIV in the 1980s and the realisation that infections can potentially be transmitted through breast milk, all these informal milk banks closed. It was only later that it was proven that pasteurisation (i.e. heating milk to 62.5 degrees Celsius) eliminates the risk of transmission. Internationally, milk banks have been re-established, with America and Europe at the forefront. Australia has been slower to introduce formal milk banks again.
A milk bank is an organisation, usually associated with a hospital, which collects, stores, processes and dispenses donated human milk. Donor human milk is excess human milk provided by a mother for use by a recipient that is not the mother’s own baby. This recipient is usually a hospitalised preterm or ill infant. The milk should be donated on a voluntary, non remunerated basis. Donor human milk is an alternative to infant formula for special needs infants, not a substitute for the mother’s own milk.
How many breast milk donors are needed for a breast milk bank?
In short, as many as possible! While preterm infants do not consume a lot of milk initially, the sheer numbers of infants that could potentially benefit from donor human milk is enormous. We also aim to eventually be able to offer pasteurised donor human milk (PDHM) to the other secondary hospitals in Queensland. (The ones that look after preterm infants).
Please could you outline the procedure by which women can donate breast milk?
Mothers who have an excess of milk supply will make the best donors. We cannot accept milk from mothers who do not have enough milk for their own infants.
Donors will need to provide us with information regarding medication, smoking and alcohol use, some of which may preclude them from donating.
At the moment, the easiest way is to e-mail our milk bank manager at Milk_bank_RBWH@health.qld.gov.au
There is a donor questionnaire, very similar to the questionnaire for blood donations. If the donor is suitable from the questionnaire, an interview will be scheduled, where further information will be given. Donors will need to have blood tests to exclude blood borne infections. (Similar to tests performed for blood donations).
Does the breast milk need to be screened?
We have to do everything we can to ensure the safety of donor milk for fragile preterm infants. In addition to screening the donors, milk will be screened for bacteria before and after pasteurising, to make sure that there are no bacteria growing in the milk.
How does the current supply of breast milk compare to the demand?
As we have just started, it is difficult to give you an accurate answer. We have been getting lots of offers for donations and currently have 3 babies on donor milk.
How many breast milk banks are there now in Australia and how does this compare to other countries?
There are five: One in Perth, Melbourne, and a private one in Northern New South Wales and now one in Brisbane. RPA hospital in Sydney has a small bank supplying inborn babies.
What are the main challenges to setting up a breast milk bank?
For us, setting up the RBWH Milk Bank it has been mainly financial. Milk banks are very expensive to set up and also very expensive to run. Set up costs will vary from $200000 - $250000. Running costs will vary as well from $150000 - $250000 per annum. We were able to raise money through our Royal Brisbane and Women’s Hospital Foundation. In the end it was a private/public collaboration to fund the milk bank.
The other challenge is to obtain everyone’s full buy in. This is a fairly new thing to Australia. This is compounded by the fact that milk banks are not regulated or controlled by any authority or body. There are no existing standards or guidelines.
Human milk is not currently recognised as a food or therapeutic good under existing Australian legislation. This means that individual banks will have the responsibility of ensuring safety of the product. We were able to bench mark from the other two large hospital based milk banks in Perth and Melbourne.
Another challenge was to find a microbiology laboratory to perform the tests we needed. Ultimately we decided on a laboratory with food based testing. Space in a hospital in always at a premium, so we had to adapt a meeting room for our purposes, all of which added to the cost.
A milk bank needs to be able to track each individual donor’s milk to each individual recipient, to ensure traceability. We could not find a suitable tracking system to purchase, so our Information Technology Services department has designed a system for us.
Would you like to make any further comments?
Pasteurised donor human milk is an important therapeutic resource in the care of very low birth weight infants. Ultimately a milk bank should be part of a package to promote and support breastfeeding. As such it needs to be integrated into existing breastfeeding support services.
Where can readers find more information?
About Dr Pieter Koorts
Dr Koorts is the Deputy Director of Neonatology and a Senior Staff Specialist Neonatologist at the Grantley Stable Neonatal Unit at the Royal Brisbane and Women’s Hospital in Brisbane, Queensland.
He is also the Medical Director of the newly opened RBWH Milk Bank. He is dual South African and Australian trained.