Over the last hundred years or so, milk banking has had its share of let-downs. But the mid-1980s were probably the worst time of all: a string of viral, legal, and commercial threats shut down many of these facilities where women could donate human milk to be given to unrelated sick babies in need.
"When the AIDS scare began, because of safety concerns around donor screening and milk processing procedures, many North American milk banks closed, almost overnight," recounts Frances Jones, RN and co-ordinator of the British Columbia Women's Hospital Milk Bank. "At the same time, the formula companies stepped in with their 'wonderful cost-effective' solution and that was it."
More than 20 years later, BC Women's is still Canada's only fully operational donor milk bank.
Donor milk has a long and storied history. Rules about 'wet-nursing,' women breastfeeding other people's babies, can be found in the Code of Hammurabi, written nearly 5000 years ago. In those days, it was thought that emotional and intellectual qualities of the nurse would be passed to the baby through the milk and so women were advised to carefully choose who should feed their babies.
By the middle ages, some European women were making a living as wet nurses. But as the knowledge of bacteria and disease transmission grew in the late 19th century, casual wet-nursing for profit fell out of favour. Instead, artificial formulas were introduced, and a formal system of milk banking was established. By the 1930s, milk banks were all over Europe and North America. They significantly aided the huge progress made in saving sick and premature babies who until that time would not normally have survived.
Re-establishing the milk flow
While concerns about transmitting viral and bacterial disease through donated breast milk are serious, so is the need for donor milk. "Some babies are highly allergic to formulas and the new mother is not in a position to provide," says Jones. "It may be that she has breast cancer or even died in childbirth." For these babies, many of whom are also very sick or born premature and therefore vulnerable, there are few options. And unless the infant is in one of the few places left with a milk bank in North America, the best option is not available.
Human breast milk is the ultimate food for healthy newborns. From a nutritional standpoint, it is perfect. However, breast milk contains much more than nutrition; it is full of growth factors, antibodies, and other substances that protect babies from infection and other diseases as they grow. For sick, weakened, or premature babies, these substances can be of vital importance in the healing process.
The question is: can donated human milk distribution be made safe and available for these babies in need?
The short answer is yes.
In 1985, the Human Milk Banking Association of North America (HMBANA) was established in part to create standards for milk banking. These standards include screening for donors and processes for treating and handling donor milk. The thought is, by making sure the donors are free of infectious disease and by removing harmful bacteria and viruses from donated milk, babies who receive it will be safe.
"We have pasteurized milk almost from day one, but in those days there was not a standardized approach," says Jones, who is also the current president of HMBANA. "When the AIDS thing happened, there was a call for more standardization of pasteurization methods and testing. HMBANA was formed to establish a standard."
Pasteurization of human milk is more or less the same process of pasteurization that is done to the cow's milk many people drink every day. Essentially, the milk is heated until any bacteria and viruses are dead. There are several ways to pasteurize: you can use a lower temperature over a longer duration, called the Holder Method, or a higher temperature for a shorter duration (HTSD).
"HTSD is something the dairy industry uses. The evidence shows it retains more beneficial properties and maintains the safety," explains Jones. "The problem is we are processing perhaps hundreds of ounces, while the dairy industry is processing thousands of litres. No machine exists for these small amounts." Consequently, milk banks use the Holder Method, which also has an excellent safety record. "You do lose some of the active properties of the milk but you retain many."
Making deposits at the bank
"Milk donors are a special group. It's a lot of work: the screening is very personal and includes blood tests, there is also the maintenance of the equipment, and adhering to storage techniques," says Jones. "Unlike blood donation, it's something you commit to every day, and donors do all this for children they never see and get very little recognition for the effort. It's a labour of love." Because of the commitment and the organization needed to donate, Jones says many of the donors are type 'A' personalities.
Others have more personally profound and tragic reasons to donate. They have extra milk because they have lost their baby. "One woman said to me by expressing milk, she would grieve the baby and it helped her work through the tragedy," says Jones, who gently lets women in this situation know that their milk could be of value to others. "We never pressure women to donate but most women quickly feel good about it because it gives meaning to the death of their baby."
Even with these women willing to donate, demand always outstrips supply. "The hardest part is turning down people in need. There is not enough milk for people who need it."
The ick factor
Jones says in addition to a general lack of milk banks, there are other more social impediments to donation. When milk banking comes up, it tends to elicit two reactions. "One is around safety and that's based on ignorance. There has never been a recorded case of illness from donor milk." Jones says this in not the case with artificial feeding with infant formulas.
"The second is the 'ick' factor. People say "Ewww, it's body fluid", but where do you think formula comes from? It's made from animal body fluid. In general, people don't think about where food comes from, and this type of reaction to human breast milk is just part of that."
Withdrawals at the bank
Of course, sick infants have no such concern, and their parents tend to quickly be reassured over safety and get over the 'ick' factor. "We start with the sickest babies. How long the baby gets milk depends on the circumstances," says Jones, adding that one baby was fed for an entire year, though "usually it's much more short term, like a few months. Sometimes it's just propping up for a while until mum starts producing again." Prioritizing which baby gets served first and for how long is not easy; however, there is at least one reason a baby won't be considered. "If the mother has chosen not to breastfeed, they don't qualify," says Jones. "Out of thousands of inquiries, we get about one call a year like this."
Currently in British Columbia, donor milk is not covered by public health insurance - though efforts are underway to rectify this situation.
Opening new branches
Although Vancouver has managed to hold on to its milk bank through good times and bad, the rest of Canada, including Toronto, is mostly out of luck. While arrangements can sometimes be made in certain hospitals, a formal and fully accessible donor banking system remains elusive. And, at least in Toronto's case, it's not for want of trying.
"There has been a working group for three years and we have completed the proposal but it's still early days," says Sharon Unger, MD and staff neonatologist at both Toronto's Mount Sinai and SickKids Hospitals. Despite enormous effort on the part of a many individuals and several institutions, "there's still no promise, no location, no funding, and no offer to insure what is still viewed - despite evidence to the contrary - as a risky business."
One way to overcome this perception is to go beyond HMBANA standards of safety. "We followed the HMBANA guidelines but then stepped it up. We have added the use of bar-coding systems and milk analysis," says Unger, who is also an assistant professor in the department of paediatrics at the University of Toronto. "The proposal creates a new gold standard, but that also makes it more expensive."
Dr Unger remains optimistic, noting that the value of milk banking is becoming more recognised as time goes on. As an example, she says the Canadian Paediatric Society is set to endorse a policy that hospitalized newborns should be fed with mother's milk first, donor milk second, with artificial formula as a 'distant third' option.
For more information, please go to: http://www.hmbana.org/