Image Source / Alamy
INFORMAL
Milk
Sharing: David Young-Wolff / Alamy
WHAT NURSES NEED TO KNOW
November/December 2014
Kimberly Martino, BS and Diane Spatz, PhD, RN-BC, FAAN Abstract Human milk is the ideal food for human infants. However, some infants will be in situations wherein there is insufficient human milk to meet their needs. This article addresses formal breast milk donation (donor milk) and informal sharing of breast milk. Healthcare providers are likely to encounter families who access milk by informal breast milk sharing or crossnursing. Both practices rely heavily on receiving human milk from women who are potentially unscreened for disease, medication, and illicit substances. Therefore, it is important for perinatal nurses to have adequate information to be able to inform these families of the risks and benefits of breast milk sharing. Two case exemplars are provided to illustrate the nuances of informal milk sharing. Implications for practice include providing families with information on health history and laboratory screening as well as safe milk-handling practices. Key words: Breastfeeding; Breast milk; Human milk; Infant nutrition science; Milk expression. MCN
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
369
he American Academy of Pediatrics (AAP, 2012) recommends an exclusive diet of human milk for the first 6 months of life and continued breastfeeding beyond the first year. In their 2012 policy statement, Breastfeeding and the Use of Human Milk, AAP stated, “(g)iven the documented short- and longterm medical and neurodevelopmental advantages of breastfeeding, infant nutrition should be considered a public health issue and not only a lifestyle choice” (AAP, 2012, p. e827). When a mother’s own milk is unavailable, donor milk is recommended for feeding critically ill infants (AAP, 2012; Cristofalo et al., 2013; Edwards & Spatz, 2012; Woo & Spatz, 2007). However, donor milk is generally only available to hospitalized infants. Families with infants outside the hospital setting who are unable to produce sufficient human milk on their own and understand the health benefits of human milk often turn to informal milk sharing (Perrin, Goodell, Allen, & Fogleman, 2014). According to the World Health Organization (WHO), when breastfeeding is not possible the first alternative feeding preference is feeding the mother’s own expressed milk through cup or bottle. The WHO then recommends cross-feeding, wet-nursing, or feeding another mothers expressed milk through cup or bottle. The last alternative feeding option would be formula (WHO, 2003). In this article, we discuss the current state surrounding the sale, donation, and trade of human milk. Organizations facilitating distribution of donor milk are identified, as are those involved in informal milk sharing. We outline the benefits and potential risks involved in informal milk sharing, as well as strategies to mitigate risk.
T
Why Informal Milk Sharing? Although WHO and AAP recommend exclusive human milk for the first 6 months of life, many infants are born into situations in which exclusive breastfeeding is unlikely, not recommended, or impossible (Centers for Disease Control and Prevention, 2013). Families who adopt children without a currently lactating adoptive mother, women with breast hypoplasia or insufficient glandular tissue, mothers who are HIV-positive, and families who experience maternal death during or after childbirth are all potential consumers of human milk donation or milk sharing practices. As these families are unlikely to be priority recipients of or be able to afford milk from Human Milk Banking Association of North America (HMBANA) banks, it is important for nurses to identify them and provide education about risks and benefits of informal milk sharing. Mothers who experience early challenges with breastfeeding may also seek informally shared milk. Infants with ankyloglossia or a short lingual frenulum (colloquially called tongue and lip ties) are at risk for ineffective breastfeeding and therefore their mothers are at risk for being unable to establish adequate milk supply (Buryk, Bloom, & Shope, 2011; Riordan & Wambach, 370
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2010). According to Webb, Hao, and Hong (2013), infants who undergo a frenulectomy within the first week of life have better breastfeeding outcomes including increased weight gain, increased milk removal, and have decreased reports of maternal pain during breastfeeding. Unfortunately many infants with tongue tie go undiagnosed for much longer than 1 week, having detrimental effects on breastfeeding and maternal milk supply (Buryk et al., 2011; Riordan & Wambach, 2010; Webb et al., 2013).
Methods of Procuring Milk Cross-Feeding
The practice of milk sharing through wet nurses has been documented from the “earliest times” in cultures ranging from ancient Egypt, India, and Greece (Wickes, 1953). This was common practice through the mid20th century. As the prevalence of breastfeeding declined through the latter half of the 1900s, so did the provision of human milk to infants from mothers not their own. Janet Golden (1996) argues that “renewable body assets,” such as human milk, are deeply tied to race and class. Such is the case with the practice of wet nurses. Thorley (2008) defines the difference between wet-nursing and cross-feeding: Wet-nursing and cross-feeding both involve the breastfeeding of a child by someone other than the mother. Wet-nursing involves a woman who is not the social equal of the employer, is never reciprocal, and is normally for payment. Cross-feeding (also ‘cross-nursing’) is the informal sharing of breastfeeding between equals, and is usually unpaid and may be reciprocal. (p. 25) As the term wet-nurse seems inseparable from power hierarchy, the practice of nursing a child other than one’s own as a gift between equals rather than a paid service is referred to as cross-nursing or shared-nursing. Donor Milk
Currently HMBANA lists 15 nonprofit milk bank locations across Canada and the United States, with five additional milk banks under development. HMBANA banks rigorously screen potential donors for infection, medication, and other lifestyle factors that could lead to milk contamination. Donated milk is mixed and processed via pasteurization (O’Hare, Wood, & Fiske, 2013). Donor milk can also be purchased through a for-profit company, Prolacta, which screens and processes milk in a similar fashion to HMBANA milk banks (Prolacta Bioscience, 2010). Purchase of human milk from any of the HMBANA member banks or from Prolacta requires a prescription. Top priority is given first to infants in the NICU of the associated hospital and secondly to sick infants residing in NICUs serviced by other HMBANA milk banks. The large number of infants who do not fall into those November/December 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Some infants are raised in families that are unable to provide sufficient human milk to meet their infant’s need.
categories are low priority to receive donor milk. Additionally, donor milk from a HMBANA milk bank is cost prohibitive for most families at $3.50 to $6.00 an ounce (K. Updegrove, Personal Communication, December 3, 2013). At 25 ounces a day, donor milk would cost $87.50 to $150 a day or up to $1,050 a week. Informal Milk Sharing
Informal milk sharing is the exchange of expressed milk from a lactating woman to families in need of human milk. It is important to differentiate between organizations that promote the commerce-free sharing of human milk and those that engage in the sale of it. Based on current research, it is clear that milk sold over the Internet carries a higher risk of contamination compared to donor milk (Keim et al., 2013). However, there is currently no research on women who share milk (commerce-free sharing) related to safety and/or microbial contamination. Organizations such as Human Milk for Human Babies (HM4HB) and Eats on Feets use social media sites to connect those seeking human milk with lactating mothers who have excess. These organizations strictly promote commerce-free sharing of human milk. With groups organized by geography, HM4HB is a vehicle to not only provide milk to infants in need but to connect families and create community. Social media communities are making use of the most recent technology on sorting and searching posted information. On HM4HB, the members use hash tags to organize those that have milk to give and families seeking it. Mothers with available milk will label their posts with “#milk2share,” “#HM4HB,” and “#milkshare.” Families in need of milk can preface their posts with “REQUEST” to indicate their need. Although the HM4HB pages are organized by state or region, users further refine their location by using the hash tag to flag their city (“#Rockford”) or region (“#UP”). Clicking any of the hash-tagged phrases will populate a list of all the mentions of that same hash-tagged phrase. Using these hyperlinked labels allows for real time, automated sorting of donors’ and recipients’ requests. Perrin et al. (2014) analyzed nine state HM4HB groups and found that there are active communities of thousands of individuals across the United States participating in the direct exchange of human milk. November/December 2014
Recent Research on Milk Purchased via the Internet In recent years, the Internet has been a platform for the sale of human milk. Research on this topic is in its infancy. Geraghty et al. (2013) documented the purchase of 2,131 ounces of human milk over the Internet from 102 sellers. Their conclusion is best summed up in the adage buyer beware. In this research, an overwhelming portion of the milk purchased over the Internet was deemed damaged (60%) or unsafe (45%). A quarter of the milk had severe damage to either its packaging or the milk container itself. Much of it was above safe temperatures; 89% arrived above -20 °C and 45% arrived above 4 °C (Geraghty et al., 2013). Given these research findings, one must consider the following questions: Is this milk indeed human milk? Are there viruses, bacteria, or other pathogens in this milk? Does this milk contain drugs or medication? How old is this milk? Has it been handled properly and kept at a safe temperature? This same group of researchers also compared bacterial growth in human milk that “came from donors temporarily disqualified per HMBANA guidelines (e.g., contraindicated medication use) or exceeded guidelines for how long ago the milk had been expressed (6 months)” to samples purchased off the Internet in a fashion similar to the above study (Keim et al., 2013, p. e1229). The results answered some pertinent questions. Milk purchased over the Internet had a higher rate of bacterial contamination than samples from HMBANA (Keim et al., 2013). Other questions still remained unanswered. The most practical of which seems to be: Is there evidence to suggest efficacious practices to destroy the microbes found in the milk in the study? Can families seeking to informally share on the Internet mitigate their risk?
Case Studies of Informal Milk Sharing Two case studies follow to illustrate the nuances of the informal milk sharing practices discussed above and to provide context for practice implications. Baby C
In early 2013, baby C was born in the Midwest. Her mother had breastfed a previous child and was enthusiastic to MCN
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371
breastfeed again. C’s mother knew something was wrong when the baby’s latch was excruciatingly painful. In her first 2 weeks of life, baby C was severely jaundiced, did not regain her birthweight, and never seemed satisfied after breastfeeding. Her mother’s nipples were severely damaged and became infected. Baby C’s mother attempted to pump but found even the lowest setting on her pump to be too painful. After 14 days of attempting to breastfeed with damaged breasts and declining milk supply, baby C’s parents made the decision to stop breastfeeding and switch to formula. Baby C tolerated formula very poorly vomiting up almost as much as she would consume. She also had poor oral intake (only 1–2 ounce(s)) per feeding. At 1 month, Baby C was in the bottom 10th percentile for growth. Disheartened baby C’s mother reached out to her community on Facebook by simply asking if any friends had milk to spare. The community answered back and a group was created to feed baby C human milk. Although Baby C still struggled to consume a sufficient volume, human milk significantly reduced the amount of regurgitation. She gained 3 pounds in her first 2 months of receiving human milk. Baby C’s mother was determined to find the root cause of their breastfeeding challenges. After two family doctors and one otolaryngologist reported no root cause for the challenges, Baby C’s family brought her to a regional hospital where she was diagnosed with an extended maxillary labial frenulum, or a lip-tie (Figure 1). In her third month of life, Baby C underwent a frenulectomy. Post procedure, she immediately and without struggle consumed three times the volume she had previously been able to eat in one feeding. After the frenulectomy and 4 months of informally shared milk, she weighed 17 pounds and was in the 70th percentile. Baby C received milk from 15 women across six states. Both her parents and her doctors cite human milk as a major
Figure 1. Baby C’s Extended Maxillary Labial Frenulum Before Her Frenulectomy.
factor in her successful rebound from initial failure to thrive (S. Potter, personal communication, November 10, 2013). Baby M: In early 2009, Baby M was born and 11 hours later his mother passed away from a rare amniotic fluid embolism. Baby M’s father was determined to honor his wife’s plan to breastfeed Baby M. In desperation, he purchased $500 of donor milk from a HMBANA bank. A friend of the family immediately offered to breastfeed Baby M whenever possible. Within 3 days of Baby M’s birth, a group that would grow quickly to include nearly 25 women breastfed Baby M through just shy of his first year of life. They formed a schedule so that he was breastfed every 2 hours during the day, as well as informally sharing expressed milk so that Baby M could be bottle fed human milk during the night. As Baby M grew, so did the spacing between his feedings. Several important factors were identified by the father in the decision to cross-feed Baby M instead of exclusively bottle feeding expressed milk. Baby M’s father identified the nurturing aspect of cross-feeding. He expressed deep gratitude for the intangible benefits of cross-feeding; that these women were not just breastfeeding his son but mothering Baby M. Cross-feeding gave Baby M the opportunity to form the emotional bond that is inherent to breastfeeding (R. Goodrich, personal communication, October 11, 2013). When discussing the social and psychological aspects of cross-feeding an infant, Baby M’s father described several unexpected benefits and considerations: There was a brief discussion about how open the circle should be, and I decided immediately that I would leave all such decisions to the moms and support them. Everyone agreed that they trusted each other and did not fear any sort of hygienic issues. After all, the moms were looking after the health of each of their own babies at the same time. No medical issues emerged. (Baby M) also showed no signs of “nipple confusion” or any other attendant psychological disassociations from his schedule. In fact, he very early could distinguish the voices and footfalls of the different moms and who was nursing at a specific time (R. Goodrich, personal communication, November 10, 2013). The social aspect extended beyond the social contract regarding nursing practices between the nursing moms.
Used with the permission of Sara Potter
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The moms tended to bring their other children with them each visit, so each of the nursings was rather communal, with the children, including (Baby M’s older sister), playing and snacking and the moms generally staying beyond the nursing time until the next mom arrived, since they wanted to see each other, too. So, again, the social aspect was of high importance (R. Goodrich, personal communication, November 10, 2013). November/December 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Benefits of Informal Milk Sharing and Cross-Nursing Cross-nursing involves raw human milk fed at the breast and it is reasonable to think it may confer many of the numerous benefits unique to breastfeeding. The infant who is breastfed will enjoy better temperature regulation and increased active and passive immunity (Riordan & Wambach, 2010). Breastfed infants have decreased risk for diabetes type 1, asthma, necrotizing entercolitis, sudden infant death syndrome, and urinary tract infections, among many other benefits (Riordan & Wambach, 2010). Children who are cross-nursed may receive these same benefits. Many of these benefits are partially or entirely present in children who are bottle fed informally shared human milk. Although the child is undoubtedly privileged to the tangible benefits of receiving human milk, the families of these children also receive intangible benefits from participating in informal milk sharing. Time and time again women who participate in milk sharing as donors and families that receive it identify the exchange as the start of a friendship and the creation of community (R. Goodrich, personal communication, October 11, 2013) (S. Potter, personal communication, November 10, 2013).
Risks of Informal Milk Sharing and Cross-Nursing The use of informal milk sharing and cross-nursing is not without risk. As human milk is a bodily fluid, it can carry both pathogens and other contaminants. Viral, bacterial, and fungal transmission is possible when feeding informally shared milk. The viruses of greatest concern to an infant being fed human milk are HIV, Hepatitis B, Hepatitis C, Human Lymphotrophic T-Cell Viruses (HLT), and Syphilis. Data analyzed from one HMBANA milk bank over a 6-year time period found that 3.3% of potential donors had a blood test positive for viral or bacterial disease; however, it is estimated over half of these results may be false positives (Cohen, Xiong, & Sakamoto, 2010). In HIV-positive mothers not currently taking antiretroviral medication, only 31% had detectable HIV in their milk and work in developing nations demonstrates that home pasteurization of human milk can eliminate viral pathogenicity (IsraelBallard et al., 2007). Families that participate in cross-feeding and informal milk sharing consistently argue that the likelihood of a virally positive woman offering to milk share is slim (Shaw, 2007). Depending on the donor and recipients’ level of familiarity and concern, this risk can be addressed with a simple, honest conversation and/or laboratory testing that the recipient family could pay for. Another concern of informally shared milk is the possibility of drugs and/ or medications present in the milk, which again could be addressed through conversation/screening. Whenever milk is expressed, there is the possibility of contaminaNovember/December 2014
Table 1. Resources for Nurses and Families HMBANA Information on nonprofit milk banks www.hmbana.org/ Prolacta Information on for profit milk banks www.prolacta.com/ Mothers Milk Cooperative Information on cooperatively owned milk banks www.mothersmilk.coop/ Eats on Feets Informal milk sharing website http://eatsonfeets.org/ Human Milk 4 Human Babies Informal milk sharing group http://hm4hb.net/ American Association of Pediatrics AAP position and information on breastfeeding http://www2.aap.org/breastfeeding/ Centers for Disease Control and Prevention Information on health issues and breastfeeding www.cdc.gov/breastfeeding/ Office of Womens Health Educational information on breastfeeding www.womenshealth.gov/breastfeeding/
tion. It is important that women who share milk are expressing using properly cleaned equipment, clean containers to store milk, and that the milk is stored frozen below -4 °C.
Implications for Nursing Practice Thorough assessments during the prenatal and immediate postpartum periods are critical to insuring prompt identification of physiologic and anatomic complications that may preclude successful breastfeeding. During prenatal visits, the pregnant woman should be assessed for flat/inverted nipples, as well as for adequate breast development that suggests proper preparation for lactation. During the postpartum period, there should be thorough assessments during at least two infant feedings to insure that there are no problems with latch on and milk transfer. Better screening practices will help nurses to recognize and educate families that may informally share milk. Families without lactating mothers, those with breast hypoplasia, as well as any breastfed infant with failure to thrive are examples of families who potentially could MCN
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be accessing human milk informally. Perrin et al. (2014) found 69% of seekers on HM4HB cited lactation problems as their primary motive for requesting human milk. Families that informally share milk or cross-nurse should receive education on making the specific practice they engage in as safe as possible (Table 1). The nurse should discuss with the family the potential for disease and drug transfer in human milk. Inform families of where their donors can get blood tests done for HIV 1 and 2 antibodies, HLT I and II, Hepatitis B surface antigen, Hepatitis C antibodies, and syphilis (Riordan & Wambach, 2010). If they are accepting expressed milk, the potential for contamination of milk should be addressed. Proper cleaning of pumping equipment and storage of human milk (most preferably frozen below -4 °C) should be taught so that these measures can be discussed with the mothers sharing their milk. Home pasteurization has been shown to eliminate pathogens (Israel-Ballard et al., 2007). Most simply, families can place an uncovered sterile glass jar filled with one feeding worth of milk in a pan of water on the stove. The water and jar of milk should be heated together until the water boils at which point the milk should immediately be removed from the heat and allowed to cool to body temperature (37 °C), which takes 15 minutes on average (Israel-Ballard et al., 2007). When this protocol was used with human milk known to be HIV positive prior to heating, no sample had detectable levels of HIV after heat treatment (Israel-Ballard et al., 2007). Informal milk sharing has both anecdotal and true benefit to infants otherwise unable to access human milk; however, the practice may not be without risk. Perinatal nurses should have adequate information in order to educate patients on the risks and benefits of their health behavior choices. Nurses in both the hospital and pediatric primary care setting must have the knowledge to assist families in making their chosen practice as safe as possible.
Areas for Further Research Clearly, further research on informal milk sharing is warranted. A few suggested topics are as follows. Does the baby fed by cross-nursing have a better immune system than one breastfed by only his mother? Is there a difference in the prevalence of milk contamination between milk that is informally purchased (i.e., not donor milk) versus commerce free milk sharing? What are the safest and most effective methods of home treatment of informally exchanged human milk (destroy harmful components while retaining beneficial components)? ✜
Kimberly Martino is a BSN student, University of Pennsylvania, Philadelphia, PA. She can be reached via e-mail at [email protected] Diane Spatz is a Professor of Perinatal Nursing and Helen M. Shearer Term Professor of Nutrition, University of Pennsylvania, Philadelphia, PA. 374
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The authors declare no conflict of interest financial, institutional, or otherwise. DOI:10.1097/NMC.0000000000000077 References American Academy of Pediatrics. (2012). Breastfeeding and the use of human milk. Pediatrics, 129(3), e827-e841. doi:10.1542/peds.20113552 Buryk, M., Bloom, D., & Shope, T. (2011). Efficacy of neonatal release of ankyloglossia: A randomized trial. Pediatrics, 128(2), 280-288. doi:10.1542/peds.2011-0077 Centers for Disease Control and Prevention; Center for Chronic Disease Prevention and Health Promotion, Division of Nutrition, Physical Activity, and Obesity. (2013). Breast Feeding Report Card 2013. Retrieved from www.cdc.gov/breastfeeding/ pdf/2013BreastfeedingReportCard.pdf Cohen, R. S., Xiong, S. C., & Sakamoto, P. (2010). Retrospective review of serological testing of potential human milk donors. Archives of Disease in Childhood-Fetal and Neonatal Edition, 95(2), F118-F120. doi:10.1136/adc.2008.156471 Cristofalo, E. A., Schanler, R. J., Blanco, C. L., Sullivan, S., Trawoeger, R., Kiechl-Kohlendorfer, U., . . ., Abrams, S. (2013). Randomized trial of exclusive human milk versus preterm formula diets in extremely premature infants. The Journal of Pediatrics, 163(6), 1592-1595.e1. doi:10.1016/j.jpeds.2013.07.011 Edwards, T. M., & Spatz, D. L. (2012). Making the case for using donor human milk in vulnerable infants. Advances in Neonatal Care, 12(5), 273-278. doi:10.1097/ANC.0b013e31825eb094 Geraghty, S. R., McNamara, K. A., Dillon, C. E., Hogan, J. S., Kwiek, J. J., & Keim, S. A. (2013). Buying human milk via the internet: Just a click away. Breastfeeding Medicine, 8(6), 474-478. doi:10.1089/ bfm.2013.0048 Golden, J. (1996). From commodity to gift: Gender, class, and the meaning of breast milk in the twentieth century. Historian, 59(1), 75-87. doi:10.1111/j.1540-6563.1996.tb00985.x Human Milk Banking Association of North America. HMBANA Milk Bank Locations. Retrieved from www.hmbana.org/milk-bank-locations Israel-Ballard, K., Donovan, R., Chantry, C., Coutsoudis, A., Sheppard, H., Sibeko, L., & Abrams, B. (2007). Flash-heat inactivation of HIV-1 in human milk: A potential method to reduce postnatal transmission in developing countries. Journal of Acquired Immune Deficiency Syndromes, 45(3), 318-323. Keim, S. A., Hogan, J. S., McNamara, K. A., Gudimetla, V., Dillon, C. E., Kwiek, J. J., & Geraghty, S. R. (2013). Microbial contamination of human milk purchased via the internet. Pediatrics, 132(5), e1227e1235. doi:10.1542/peds.2013-1687 O’Hare, E. M., Wood, A., & Fiske, E. (2013). Human milk banking. Neonatal Network, 32(3), 175-183. doi:10.1891/0730-0832.32.3.175 Perrin, M. T., Goodell, L. S., Allen, J. C., & Fogleman, A. (2014). A mixedmethods observational study of human milk sharing communities on Facebook. Breastfeeding Medicine, 9(3), 128-134. Prolacta Bioscience. (2010). Prolacta’s State-of-the-Art Testing, Screening, and Standardized Production Process. [Brochure]. Retrieved from www.prolacta.com/docs/MKT-0173%20Rev-1%20Prolactas%20 State-of-the-Art%20Testing,%20Screening,%20and%20Standard ized%20Production %20Process.pdf Riordan, J., & Wambach, K. (2010). Breastfeeding and human lactation. Sudbury: Jones and Bartlett Publishers. Shaw, R. (2007). Cross-nursing, ethics, and giving breast milk in the contemporary context. Women’s Studies International Forum, 30(5), 439-450. doi:10.1016/j.wsif.2007.07.001 Thorley, V. (2008). Sharing breastmilk: Wet nursing, cross feeding, and milk donations. Breastfeeding Review, 16(1), 25-29. Webb, A. N., Hao, W., & Hong, P. (2013). The effect of tongue-tie division on breastfeeding and speech articulation: A systematic review. International Journal of Pediatric Otorhinolaryngology, 77(5), 635646. doi:10.1016/j.ijporl.2013.03.008 Wickes, I. G. (1953). A history of infant feeding. I. Primitive peoples; ancient works; Renaissance writers. Archives of Disease in Childhood, 28(138), 151-158. Woo, K., & Spatz, D. (2007). Human milk donation: What do you know about it? MCN. The American Journal of Maternal/Child Nursing, 32(3), 150-155. doi:10.1097/01.NMC.0000269563.42982.64 World Health Organization. (2003). Global Strategy for Infant and Young Child Feeding. WHO Library, 10. Retrieved from http://whqlibdoc. who.int/publications/2003/9241562218.pdf November/December 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
INFORMAL
Milk
Sharing: David Young-Wolff / Alamy
WHAT NURSES NEED TO KNOW
November/December 2014
Kimberly Martino, BS and Diane Spatz, PhD, RN-BC, FAAN Abstract Human milk is the ideal food for human infants. However, some infants will be in situations wherein there is insufficient human milk to meet their needs. This article addresses formal breast milk donation (donor milk) and informal sharing of breast milk. Healthcare providers are likely to encounter families who access milk by informal breast milk sharing or crossnursing. Both practices rely heavily on receiving human milk from women who are potentially unscreened for disease, medication, and illicit substances. Therefore, it is important for perinatal nurses to have adequate information to be able to inform these families of the risks and benefits of breast milk sharing. Two case exemplars are provided to illustrate the nuances of informal milk sharing. Implications for practice include providing families with information on health history and laboratory screening as well as safe milk-handling practices. Key words: Breastfeeding; Breast milk; Human milk; Infant nutrition science; Milk expression. MCN
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
369
he American Academy of Pediatrics (AAP, 2012) recommends an exclusive diet of human milk for the first 6 months of life and continued breastfeeding beyond the first year. In their 2012 policy statement, Breastfeeding and the Use of Human Milk, AAP stated, “(g)iven the documented short- and longterm medical and neurodevelopmental advantages of breastfeeding, infant nutrition should be considered a public health issue and not only a lifestyle choice” (AAP, 2012, p. e827). When a mother’s own milk is unavailable, donor milk is recommended for feeding critically ill infants (AAP, 2012; Cristofalo et al., 2013; Edwards & Spatz, 2012; Woo & Spatz, 2007). However, donor milk is generally only available to hospitalized infants. Families with infants outside the hospital setting who are unable to produce sufficient human milk on their own and understand the health benefits of human milk often turn to informal milk sharing (Perrin, Goodell, Allen, & Fogleman, 2014). According to the World Health Organization (WHO), when breastfeeding is not possible the first alternative feeding preference is feeding the mother’s own expressed milk through cup or bottle. The WHO then recommends cross-feeding, wet-nursing, or feeding another mothers expressed milk through cup or bottle. The last alternative feeding option would be formula (WHO, 2003). In this article, we discuss the current state surrounding the sale, donation, and trade of human milk. Organizations facilitating distribution of donor milk are identified, as are those involved in informal milk sharing. We outline the benefits and potential risks involved in informal milk sharing, as well as strategies to mitigate risk.
T
Why Informal Milk Sharing? Although WHO and AAP recommend exclusive human milk for the first 6 months of life, many infants are born into situations in which exclusive breastfeeding is unlikely, not recommended, or impossible (Centers for Disease Control and Prevention, 2013). Families who adopt children without a currently lactating adoptive mother, women with breast hypoplasia or insufficient glandular tissue, mothers who are HIV-positive, and families who experience maternal death during or after childbirth are all potential consumers of human milk donation or milk sharing practices. As these families are unlikely to be priority recipients of or be able to afford milk from Human Milk Banking Association of North America (HMBANA) banks, it is important for nurses to identify them and provide education about risks and benefits of informal milk sharing. Mothers who experience early challenges with breastfeeding may also seek informally shared milk. Infants with ankyloglossia or a short lingual frenulum (colloquially called tongue and lip ties) are at risk for ineffective breastfeeding and therefore their mothers are at risk for being unable to establish adequate milk supply (Buryk, Bloom, & Shope, 2011; Riordan & Wambach, 370
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2010). According to Webb, Hao, and Hong (2013), infants who undergo a frenulectomy within the first week of life have better breastfeeding outcomes including increased weight gain, increased milk removal, and have decreased reports of maternal pain during breastfeeding. Unfortunately many infants with tongue tie go undiagnosed for much longer than 1 week, having detrimental effects on breastfeeding and maternal milk supply (Buryk et al., 2011; Riordan & Wambach, 2010; Webb et al., 2013).
Methods of Procuring Milk Cross-Feeding
The practice of milk sharing through wet nurses has been documented from the “earliest times” in cultures ranging from ancient Egypt, India, and Greece (Wickes, 1953). This was common practice through the mid20th century. As the prevalence of breastfeeding declined through the latter half of the 1900s, so did the provision of human milk to infants from mothers not their own. Janet Golden (1996) argues that “renewable body assets,” such as human milk, are deeply tied to race and class. Such is the case with the practice of wet nurses. Thorley (2008) defines the difference between wet-nursing and cross-feeding: Wet-nursing and cross-feeding both involve the breastfeeding of a child by someone other than the mother. Wet-nursing involves a woman who is not the social equal of the employer, is never reciprocal, and is normally for payment. Cross-feeding (also ‘cross-nursing’) is the informal sharing of breastfeeding between equals, and is usually unpaid and may be reciprocal. (p. 25) As the term wet-nurse seems inseparable from power hierarchy, the practice of nursing a child other than one’s own as a gift between equals rather than a paid service is referred to as cross-nursing or shared-nursing. Donor Milk
Currently HMBANA lists 15 nonprofit milk bank locations across Canada and the United States, with five additional milk banks under development. HMBANA banks rigorously screen potential donors for infection, medication, and other lifestyle factors that could lead to milk contamination. Donated milk is mixed and processed via pasteurization (O’Hare, Wood, & Fiske, 2013). Donor milk can also be purchased through a for-profit company, Prolacta, which screens and processes milk in a similar fashion to HMBANA milk banks (Prolacta Bioscience, 2010). Purchase of human milk from any of the HMBANA member banks or from Prolacta requires a prescription. Top priority is given first to infants in the NICU of the associated hospital and secondly to sick infants residing in NICUs serviced by other HMBANA milk banks. The large number of infants who do not fall into those November/December 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Some infants are raised in families that are unable to provide sufficient human milk to meet their infant’s need.
categories are low priority to receive donor milk. Additionally, donor milk from a HMBANA milk bank is cost prohibitive for most families at $3.50 to $6.00 an ounce (K. Updegrove, Personal Communication, December 3, 2013). At 25 ounces a day, donor milk would cost $87.50 to $150 a day or up to $1,050 a week. Informal Milk Sharing
Informal milk sharing is the exchange of expressed milk from a lactating woman to families in need of human milk. It is important to differentiate between organizations that promote the commerce-free sharing of human milk and those that engage in the sale of it. Based on current research, it is clear that milk sold over the Internet carries a higher risk of contamination compared to donor milk (Keim et al., 2013). However, there is currently no research on women who share milk (commerce-free sharing) related to safety and/or microbial contamination. Organizations such as Human Milk for Human Babies (HM4HB) and Eats on Feets use social media sites to connect those seeking human milk with lactating mothers who have excess. These organizations strictly promote commerce-free sharing of human milk. With groups organized by geography, HM4HB is a vehicle to not only provide milk to infants in need but to connect families and create community. Social media communities are making use of the most recent technology on sorting and searching posted information. On HM4HB, the members use hash tags to organize those that have milk to give and families seeking it. Mothers with available milk will label their posts with “#milk2share,” “#HM4HB,” and “#milkshare.” Families in need of milk can preface their posts with “REQUEST” to indicate their need. Although the HM4HB pages are organized by state or region, users further refine their location by using the hash tag to flag their city (“#Rockford”) or region (“#UP”). Clicking any of the hash-tagged phrases will populate a list of all the mentions of that same hash-tagged phrase. Using these hyperlinked labels allows for real time, automated sorting of donors’ and recipients’ requests. Perrin et al. (2014) analyzed nine state HM4HB groups and found that there are active communities of thousands of individuals across the United States participating in the direct exchange of human milk. November/December 2014
Recent Research on Milk Purchased via the Internet In recent years, the Internet has been a platform for the sale of human milk. Research on this topic is in its infancy. Geraghty et al. (2013) documented the purchase of 2,131 ounces of human milk over the Internet from 102 sellers. Their conclusion is best summed up in the adage buyer beware. In this research, an overwhelming portion of the milk purchased over the Internet was deemed damaged (60%) or unsafe (45%). A quarter of the milk had severe damage to either its packaging or the milk container itself. Much of it was above safe temperatures; 89% arrived above -20 °C and 45% arrived above 4 °C (Geraghty et al., 2013). Given these research findings, one must consider the following questions: Is this milk indeed human milk? Are there viruses, bacteria, or other pathogens in this milk? Does this milk contain drugs or medication? How old is this milk? Has it been handled properly and kept at a safe temperature? This same group of researchers also compared bacterial growth in human milk that “came from donors temporarily disqualified per HMBANA guidelines (e.g., contraindicated medication use) or exceeded guidelines for how long ago the milk had been expressed (6 months)” to samples purchased off the Internet in a fashion similar to the above study (Keim et al., 2013, p. e1229). The results answered some pertinent questions. Milk purchased over the Internet had a higher rate of bacterial contamination than samples from HMBANA (Keim et al., 2013). Other questions still remained unanswered. The most practical of which seems to be: Is there evidence to suggest efficacious practices to destroy the microbes found in the milk in the study? Can families seeking to informally share on the Internet mitigate their risk?
Case Studies of Informal Milk Sharing Two case studies follow to illustrate the nuances of the informal milk sharing practices discussed above and to provide context for practice implications. Baby C
In early 2013, baby C was born in the Midwest. Her mother had breastfed a previous child and was enthusiastic to MCN
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breastfeed again. C’s mother knew something was wrong when the baby’s latch was excruciatingly painful. In her first 2 weeks of life, baby C was severely jaundiced, did not regain her birthweight, and never seemed satisfied after breastfeeding. Her mother’s nipples were severely damaged and became infected. Baby C’s mother attempted to pump but found even the lowest setting on her pump to be too painful. After 14 days of attempting to breastfeed with damaged breasts and declining milk supply, baby C’s parents made the decision to stop breastfeeding and switch to formula. Baby C tolerated formula very poorly vomiting up almost as much as she would consume. She also had poor oral intake (only 1–2 ounce(s)) per feeding. At 1 month, Baby C was in the bottom 10th percentile for growth. Disheartened baby C’s mother reached out to her community on Facebook by simply asking if any friends had milk to spare. The community answered back and a group was created to feed baby C human milk. Although Baby C still struggled to consume a sufficient volume, human milk significantly reduced the amount of regurgitation. She gained 3 pounds in her first 2 months of receiving human milk. Baby C’s mother was determined to find the root cause of their breastfeeding challenges. After two family doctors and one otolaryngologist reported no root cause for the challenges, Baby C’s family brought her to a regional hospital where she was diagnosed with an extended maxillary labial frenulum, or a lip-tie (Figure 1). In her third month of life, Baby C underwent a frenulectomy. Post procedure, she immediately and without struggle consumed three times the volume she had previously been able to eat in one feeding. After the frenulectomy and 4 months of informally shared milk, she weighed 17 pounds and was in the 70th percentile. Baby C received milk from 15 women across six states. Both her parents and her doctors cite human milk as a major
Figure 1. Baby C’s Extended Maxillary Labial Frenulum Before Her Frenulectomy.
factor in her successful rebound from initial failure to thrive (S. Potter, personal communication, November 10, 2013). Baby M: In early 2009, Baby M was born and 11 hours later his mother passed away from a rare amniotic fluid embolism. Baby M’s father was determined to honor his wife’s plan to breastfeed Baby M. In desperation, he purchased $500 of donor milk from a HMBANA bank. A friend of the family immediately offered to breastfeed Baby M whenever possible. Within 3 days of Baby M’s birth, a group that would grow quickly to include nearly 25 women breastfed Baby M through just shy of his first year of life. They formed a schedule so that he was breastfed every 2 hours during the day, as well as informally sharing expressed milk so that Baby M could be bottle fed human milk during the night. As Baby M grew, so did the spacing between his feedings. Several important factors were identified by the father in the decision to cross-feed Baby M instead of exclusively bottle feeding expressed milk. Baby M’s father identified the nurturing aspect of cross-feeding. He expressed deep gratitude for the intangible benefits of cross-feeding; that these women were not just breastfeeding his son but mothering Baby M. Cross-feeding gave Baby M the opportunity to form the emotional bond that is inherent to breastfeeding (R. Goodrich, personal communication, October 11, 2013). When discussing the social and psychological aspects of cross-feeding an infant, Baby M’s father described several unexpected benefits and considerations: There was a brief discussion about how open the circle should be, and I decided immediately that I would leave all such decisions to the moms and support them. Everyone agreed that they trusted each other and did not fear any sort of hygienic issues. After all, the moms were looking after the health of each of their own babies at the same time. No medical issues emerged. (Baby M) also showed no signs of “nipple confusion” or any other attendant psychological disassociations from his schedule. In fact, he very early could distinguish the voices and footfalls of the different moms and who was nursing at a specific time (R. Goodrich, personal communication, November 10, 2013). The social aspect extended beyond the social contract regarding nursing practices between the nursing moms.
Used with the permission of Sara Potter
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The moms tended to bring their other children with them each visit, so each of the nursings was rather communal, with the children, including (Baby M’s older sister), playing and snacking and the moms generally staying beyond the nursing time until the next mom arrived, since they wanted to see each other, too. So, again, the social aspect was of high importance (R. Goodrich, personal communication, November 10, 2013). November/December 2014
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Benefits of Informal Milk Sharing and Cross-Nursing Cross-nursing involves raw human milk fed at the breast and it is reasonable to think it may confer many of the numerous benefits unique to breastfeeding. The infant who is breastfed will enjoy better temperature regulation and increased active and passive immunity (Riordan & Wambach, 2010). Breastfed infants have decreased risk for diabetes type 1, asthma, necrotizing entercolitis, sudden infant death syndrome, and urinary tract infections, among many other benefits (Riordan & Wambach, 2010). Children who are cross-nursed may receive these same benefits. Many of these benefits are partially or entirely present in children who are bottle fed informally shared human milk. Although the child is undoubtedly privileged to the tangible benefits of receiving human milk, the families of these children also receive intangible benefits from participating in informal milk sharing. Time and time again women who participate in milk sharing as donors and families that receive it identify the exchange as the start of a friendship and the creation of community (R. Goodrich, personal communication, October 11, 2013) (S. Potter, personal communication, November 10, 2013).
Risks of Informal Milk Sharing and Cross-Nursing The use of informal milk sharing and cross-nursing is not without risk. As human milk is a bodily fluid, it can carry both pathogens and other contaminants. Viral, bacterial, and fungal transmission is possible when feeding informally shared milk. The viruses of greatest concern to an infant being fed human milk are HIV, Hepatitis B, Hepatitis C, Human Lymphotrophic T-Cell Viruses (HLT), and Syphilis. Data analyzed from one HMBANA milk bank over a 6-year time period found that 3.3% of potential donors had a blood test positive for viral or bacterial disease; however, it is estimated over half of these results may be false positives (Cohen, Xiong, & Sakamoto, 2010). In HIV-positive mothers not currently taking antiretroviral medication, only 31% had detectable HIV in their milk and work in developing nations demonstrates that home pasteurization of human milk can eliminate viral pathogenicity (IsraelBallard et al., 2007). Families that participate in cross-feeding and informal milk sharing consistently argue that the likelihood of a virally positive woman offering to milk share is slim (Shaw, 2007). Depending on the donor and recipients’ level of familiarity and concern, this risk can be addressed with a simple, honest conversation and/or laboratory testing that the recipient family could pay for. Another concern of informally shared milk is the possibility of drugs and/ or medications present in the milk, which again could be addressed through conversation/screening. Whenever milk is expressed, there is the possibility of contaminaNovember/December 2014
Table 1. Resources for Nurses and Families HMBANA Information on nonprofit milk banks www.hmbana.org/ Prolacta Information on for profit milk banks www.prolacta.com/ Mothers Milk Cooperative Information on cooperatively owned milk banks www.mothersmilk.coop/ Eats on Feets Informal milk sharing website http://eatsonfeets.org/ Human Milk 4 Human Babies Informal milk sharing group http://hm4hb.net/ American Association of Pediatrics AAP position and information on breastfeeding http://www2.aap.org/breastfeeding/ Centers for Disease Control and Prevention Information on health issues and breastfeeding www.cdc.gov/breastfeeding/ Office of Womens Health Educational information on breastfeeding www.womenshealth.gov/breastfeeding/
tion. It is important that women who share milk are expressing using properly cleaned equipment, clean containers to store milk, and that the milk is stored frozen below -4 °C.
Implications for Nursing Practice Thorough assessments during the prenatal and immediate postpartum periods are critical to insuring prompt identification of physiologic and anatomic complications that may preclude successful breastfeeding. During prenatal visits, the pregnant woman should be assessed for flat/inverted nipples, as well as for adequate breast development that suggests proper preparation for lactation. During the postpartum period, there should be thorough assessments during at least two infant feedings to insure that there are no problems with latch on and milk transfer. Better screening practices will help nurses to recognize and educate families that may informally share milk. Families without lactating mothers, those with breast hypoplasia, as well as any breastfed infant with failure to thrive are examples of families who potentially could MCN
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be accessing human milk informally. Perrin et al. (2014) found 69% of seekers on HM4HB cited lactation problems as their primary motive for requesting human milk. Families that informally share milk or cross-nurse should receive education on making the specific practice they engage in as safe as possible (Table 1). The nurse should discuss with the family the potential for disease and drug transfer in human milk. Inform families of where their donors can get blood tests done for HIV 1 and 2 antibodies, HLT I and II, Hepatitis B surface antigen, Hepatitis C antibodies, and syphilis (Riordan & Wambach, 2010). If they are accepting expressed milk, the potential for contamination of milk should be addressed. Proper cleaning of pumping equipment and storage of human milk (most preferably frozen below -4 °C) should be taught so that these measures can be discussed with the mothers sharing their milk. Home pasteurization has been shown to eliminate pathogens (Israel-Ballard et al., 2007). Most simply, families can place an uncovered sterile glass jar filled with one feeding worth of milk in a pan of water on the stove. The water and jar of milk should be heated together until the water boils at which point the milk should immediately be removed from the heat and allowed to cool to body temperature (37 °C), which takes 15 minutes on average (Israel-Ballard et al., 2007). When this protocol was used with human milk known to be HIV positive prior to heating, no sample had detectable levels of HIV after heat treatment (Israel-Ballard et al., 2007). Informal milk sharing has both anecdotal and true benefit to infants otherwise unable to access human milk; however, the practice may not be without risk. Perinatal nurses should have adequate information in order to educate patients on the risks and benefits of their health behavior choices. Nurses in both the hospital and pediatric primary care setting must have the knowledge to assist families in making their chosen practice as safe as possible.
Areas for Further Research Clearly, further research on informal milk sharing is warranted. A few suggested topics are as follows. Does the baby fed by cross-nursing have a better immune system than one breastfed by only his mother? Is there a difference in the prevalence of milk contamination between milk that is informally purchased (i.e., not donor milk) versus commerce free milk sharing? What are the safest and most effective methods of home treatment of informally exchanged human milk (destroy harmful components while retaining beneficial components)? ✜
Kimberly Martino is a BSN student, University of Pennsylvania, Philadelphia, PA. She can be reached via e-mail at [email protected] Diane Spatz is a Professor of Perinatal Nursing and Helen M. Shearer Term Professor of Nutrition, University of Pennsylvania, Philadelphia, PA. 374
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The authors declare no conflict of interest financial, institutional, or otherwise. DOI:10.1097/NMC.0000000000000077 References American Academy of Pediatrics. (2012). Breastfeeding and the use of human milk. Pediatrics, 129(3), e827-e841. doi:10.1542/peds.20113552 Buryk, M., Bloom, D., & Shope, T. (2011). Efficacy of neonatal release of ankyloglossia: A randomized trial. Pediatrics, 128(2), 280-288. doi:10.1542/peds.2011-0077 Centers for Disease Control and Prevention; Center for Chronic Disease Prevention and Health Promotion, Division of Nutrition, Physical Activity, and Obesity. (2013). Breast Feeding Report Card 2013. Retrieved from www.cdc.gov/breastfeeding/ pdf/2013BreastfeedingReportCard.pdf Cohen, R. S., Xiong, S. C., & Sakamoto, P. (2010). Retrospective review of serological testing of potential human milk donors. Archives of Disease in Childhood-Fetal and Neonatal Edition, 95(2), F118-F120. doi:10.1136/adc.2008.156471 Cristofalo, E. A., Schanler, R. J., Blanco, C. L., Sullivan, S., Trawoeger, R., Kiechl-Kohlendorfer, U., . . ., Abrams, S. (2013). Randomized trial of exclusive human milk versus preterm formula diets in extremely premature infants. The Journal of Pediatrics, 163(6), 1592-1595.e1. doi:10.1016/j.jpeds.2013.07.011 Edwards, T. M., & Spatz, D. L. (2012). Making the case for using donor human milk in vulnerable infants. Advances in Neonatal Care, 12(5), 273-278. doi:10.1097/ANC.0b013e31825eb094 Geraghty, S. R., McNamara, K. A., Dillon, C. E., Hogan, J. S., Kwiek, J. J., & Keim, S. A. (2013). Buying human milk via the internet: Just a click away. Breastfeeding Medicine, 8(6), 474-478. doi:10.1089/ bfm.2013.0048 Golden, J. (1996). From commodity to gift: Gender, class, and the meaning of breast milk in the twentieth century. Historian, 59(1), 75-87. doi:10.1111/j.1540-6563.1996.tb00985.x Human Milk Banking Association of North America. HMBANA Milk Bank Locations. Retrieved from www.hmbana.org/milk-bank-locations Israel-Ballard, K., Donovan, R., Chantry, C., Coutsoudis, A., Sheppard, H., Sibeko, L., & Abrams, B. (2007). Flash-heat inactivation of HIV-1 in human milk: A potential method to reduce postnatal transmission in developing countries. Journal of Acquired Immune Deficiency Syndromes, 45(3), 318-323. Keim, S. A., Hogan, J. S., McNamara, K. A., Gudimetla, V., Dillon, C. E., Kwiek, J. J., & Geraghty, S. R. (2013). Microbial contamination of human milk purchased via the internet. Pediatrics, 132(5), e1227e1235. doi:10.1542/peds.2013-1687 O’Hare, E. M., Wood, A., & Fiske, E. (2013). Human milk banking. Neonatal Network, 32(3), 175-183. doi:10.1891/0730-0832.32.3.175 Perrin, M. T., Goodell, L. S., Allen, J. C., & Fogleman, A. (2014). A mixedmethods observational study of human milk sharing communities on Facebook. Breastfeeding Medicine, 9(3), 128-134. Prolacta Bioscience. (2010). Prolacta’s State-of-the-Art Testing, Screening, and Standardized Production Process. [Brochure]. Retrieved from www.prolacta.com/docs/MKT-0173%20Rev-1%20Prolactas%20 State-of-the-Art%20Testing,%20Screening,%20and%20Standard ized%20Production %20Process.pdf Riordan, J., & Wambach, K. (2010). Breastfeeding and human lactation. Sudbury: Jones and Bartlett Publishers. Shaw, R. (2007). Cross-nursing, ethics, and giving breast milk in the contemporary context. Women’s Studies International Forum, 30(5), 439-450. doi:10.1016/j.wsif.2007.07.001 Thorley, V. (2008). Sharing breastmilk: Wet nursing, cross feeding, and milk donations. Breastfeeding Review, 16(1), 25-29. Webb, A. N., Hao, W., & Hong, P. (2013). The effect of tongue-tie division on breastfeeding and speech articulation: A systematic review. International Journal of Pediatric Otorhinolaryngology, 77(5), 635646. doi:10.1016/j.ijporl.2013.03.008 Wickes, I. G. (1953). A history of infant feeding. I. Primitive peoples; ancient works; Renaissance writers. Archives of Disease in Childhood, 28(138), 151-158. Woo, K., & Spatz, D. (2007). Human milk donation: What do you know about it? MCN. The American Journal of Maternal/Child Nursing, 32(3), 150-155. doi:10.1097/01.NMC.0000269563.42982.64 World Health Organization. (2003). Global Strategy for Infant and Young Child Feeding. WHO Library, 10. Retrieved from http://whqlibdoc. who.int/publications/2003/9241562218.pdf November/December 2014
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