Human Milk Banking: Straight from the heart to beat the odds

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Human Milk BankingStraight from the heart to
beat the odds

Penny Reimers RN RM IBCLC
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Outline

• Introduction
• Benefits of Donor Milk/ Uses
• Donor Mothers
• Human Milk Banks in South Africa
• International Breastmilk Project
• Current Research
• Heat Treatment
• Donor Milk and Health Policy
• International Trends
• HMBASA
• Conclusion

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Introduction

• What is Milk Banking?
• It is a service which screens, collects,
  processes and dispenses human milk that has been
  donated by volunteer nursing mothers who are not
  related to the recipient infant.
• Every effort should be made to feed fresh breast
  milk to a mothers own infant
• Donor Milk is 1st alternative
• WHO UNICEF 1980/2003
• Part of comprehensive b/f programme- Protects,
  promotes, supports b/f

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• WHO-World Health Assembly 25 th May, 2008
• Directive for countries to investigate the
  use of donor banking as a risk reduction strategy
  for infant mortality and morbidity and to do
  research to provide support on the safe use of
  donor milk

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Slide of formula vs breastmilk
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Antibacterial factors found in human milk-
Secretory Ig A

• E. coli (also pili, capsular antigens, CFA1)
  including enteropathogenic strains, C. tetani, C.
  diphtheriae, K. pneumoniae, S. pyogenes, S.
  mutans, S. sanguins, S. mitis, S. agalactiae
  (group B streptococci), S. salvarius, S.
  pneumoniae (also capsular polysaccharides), C.
  burnetti, H. influenzae. H. pylori, S. flexneri,
  S. boydii, S. sonnei, C. jejuni, N. meningitidis,
  B. pertussis, S. dysenteriae, C. trachomatis,
  Salmonella (6 groups), S. minnesota, P.
  aeruginosa, L. innocua, Campylobacter flagelin,
  Y. enterocolitica, S. flexneri virulence plasmid
  antigen, C. diphtheriae toxin, E. coli
  enterotoxin, V. cholerae enterotoxin, C.
  difficile toxins, H. influenzae capsule, S.
  aureus enterotoxin F, Candida albicans,
  Mycoplasma pneumoniae

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Antibacterial factors found in human milk

• Lactoferrin is active against
• E. coli, E. coli/CFA1 or S-fimbriae, Candida
  albicans , Candida krusei, Rhodotorula rubra,
  H. influenzae, S. flexneri, Actinobacillus
  actinomycetemcomitans
• Lipids active against
• S. aureus, E. coli, S. epidermis, H. influenzae,
  S. agalactiae, L. monocytogenes, N. gonorrhoeae,
  C. trachomatis, B. parapertusis heat-labile
  toxin, binds Shigella-like toxin-1

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Antibacterial factors found in human milk

• Milk cells (80 macrophages,15 neutrophils,0.3
  B and 4 T lymphocytes) active against
• By phagocytosis and killing E. coli, S. aureus,
  S. enteritidisBy sensitised lymphocytes E.
  coliBy phagocytosis Candida albicans, E.
  coliLymphocyte stimulation E. coli K antigen,
  tuberculinSpontaneous monokines simulated by
  lipopolysaccarideInduced cytokines PHA, PMA
  ionomycinFibronectin helps in uptake by
  phagocytic cells.
• From www.latrobe.edu.au

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Benefits of Donor Milk

• Human milk is living tissue!
• Faster emptying of stomach
• Intestinal permeability is reduced faster
• Less residuals and faster realization of full
  enteral feeds
• Factors in breast milk stimulate gastrointestinal
  growth, mobility and maturation
• Wight, N. Journal of Perinatology 2001
  21249-245

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Benefits (Cont.)

• Improved cognitive visual development (Uauy et
  al, 1990)
• Less retinopathy of prematurity (Hylander et al,
  1996)
• Enzymes in b/m help immature infants absorb and
  utilize nutrients more efficiently (Hamosh,1994)
• Immunological benefits
• Protection against NEC
• Appropriate lipid profiles (PUFAs)
• Considerable cost savings
• Relieves infants pain and discomfort parents
  anguish
• Reinforces the importance of breast
  milk/breastfeeding

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Necrotizing Enterocolitis

• Lucas Cole study( 1990)- Incidence was six-ten
  times more likely in infant fed formula
  exclusively than those fed breast milk
  exclusively
• Bisquera (2002) Found that average length of stay
  for surgical cases was 60 days longer and cost
  186,200
• Uni. of Leipzig use maternal and donor milk at
  one, two and three days post partum and have
  very low rates of NEC ( 0.2) Springer, 1997).
• Ostra Sjukhuset in Gotsborg, Sweden. Infants are
  fed maternal or banked milk within the first 6-12
  hrs of life. They start with 2-3 ml every three
  hrs slowly increasing until full enteral feeds at
  5-6 days- only see one or two cases of NEC a
  year.( NICU 800-900 admissions a year) Arnold,
  1999.

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Financial Implications- Morbidity MOM vs
Pre-term Formula
Fresh Human Milk Pre-term formula Difference
Length of stay in hospital 73 days 88 days 15 days
NEC 0.02 0.13 0.11
Late on set sepsis 0.3 0.6 0.3
Dur. of total parenteral nutrition 25 days 35 days 10 days

• Schlaner, Shulman, Lau. Pediatrics 1999 ,
  103(6)1150-1157

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Increased cost of NOT using breast milk in NICU
Morbidity Calculation Totals
LOS 15 x 600/day 9000
NEC( non-surgical) 0.11 x 2260 249
Sepsis 0.3 x 1399 420
Total cost per infant ( direct costs only) 9669
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Clinical Uses

• To supplement a mothers own supply
• For infants who are ill and have some medical
  condition
• For cases where b/f is contra indicated HIV Pos
  mother/ chemotherapy
• Preterm infants
• Maternal death
• Immune compromised babies those orphaned due to
  HIV/AIDS
• Adopted babies

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Uses of Donor Milk -USA Canada 2003

• Preventive Health
• Necrotizing enterocolitis
• AIDS
• Crohns disease
• Colitis

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Uses of Banked Human Milk in 2003 USA Canada

• Medical and Therapeutic
• Short gut syndrome
• Infectious diseases
• Postsurgical healing
• Immunologic diseases
• Renal failure
• Inborn errors of metabolism
• Nutritional
• Prematurity
• Failure to thrive
• Malabsorption syndromes
• Feeding intolerance

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Recipient Prioritization in allocation of Donor
Milk

• Prematurity
• Malabsorption
• Feeding intolerance
• Immunological deficiencies
• Congenital anomalies
• Post-operative nutrition
• Lactation failure
• Adoption
• Illness of mother
• Health risk to infant from mother
• Death of mothers

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Donor Milk Fortification?

• Composition of preterm milk ( 36 wks) term milk
  differ
• Debate on whether LBW VLBW can achieve adequate
  growth on donor milk from term mothers
• Can match gestationally appropriate milk to the
  recipient
• Can use infra red analysis to determine fat,
  protein and carbohydrate content. In Scandinavia
  they do this and pool milk to meet the
  requirements of infants
• Ultrasonic homogenization of EBM prevents fat
  adhering to feeding tubes, babies gained more
  weight( Marinez, 1989). Babies gained avg. 5
  gm/day more
• Current practice in Europe to add fortifiers to
  provide extra protein, calcium phosphorus-
  drawbacks contamination of powdered products,
  cows milk protein allergy, decreases amt of
  lysozyme and IgA esp. for E.coli

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Fortification ( cont)

• France they fractionate and freeze dry human
  milk and can fortify maternal or donor milk on an
  individual basis to bring protein content to
  3.5g/kg
• Variations in protein energy contents of human
  milk
• Schlaner, ABM, Oct, 1989, Adapted from
  Polberger 1996.

Protein(g/dL) Mean (range) Energy(kc/dL) Mean(range)
MOM 1.7 (1.1-2.7) 65 (52-79)
Preterm banked milk 1.5 (1.0-2.2) 65 (59-74)
Term banked milk 1.3 (0.9-1.7) 63 (48-77)
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Donor Mothers

• Health women who are breastfeeding their own
  babies
• Screened to ensure meet requirements
• Often have milk supply higher than the needs of
  their infant, or the supply can be stimulated by
  expressing
• Mother of a deceased infant may also donate
• Donors are not paid but are rewarded knowing they
  have helped someone
• Donor are self-selected- hear about donating
  through child birth educator, baby magazines,
  hospital staff or word of mouth

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Screening questionnaire

• Have you received a blood transfusion or blood
  products in the last 12 months?
• Do you regularly have more than 50ml of hard
  liquor or its equivalent in a 24-hour period?
• Regular use of medications, or use of
  radio-active drugs or cytotoxins?
• Are you a total vegetarian?
• If yes, do you supplement your diet with B12
  vitamins?
• Do you use habit-forming drugs?
• Do you smoke?
• Have you ever had hepatitis B, HIV, or TB?
• Have you ever had a sexual partner who is at risk
  for HIV, takes habit-forming drugs, or is a
  haemophiliac?
• Do you have a copy of the results of your
  anti-natal HIV and syphilis tests?
• If not, would you be prepared to undergo a rapid
  test for HIV at your expense and submit the
  results to the screening officer? 

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Milk donation

• Mother either express using a pump or hand
  expression
• Given details about cleaning pump
• Given storage bottles( glass best option) each
  bottle is marked with the date of expression
  donor number
• Milk is frozen at -20 C and collected from the
  mother or dropped at a collection site
• Milk is thawed and pasteurised at 62.5 C for 30
  min
• Cooled and frozen immediately
• Microbiology- Titratable Acidity test post
  pasteurisation. Petrifilm for E. coli and
  coliform bacteria

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Cultural Acceptance of Donor Milk

• Nigeria- 70 of mothers would not accept donor
  milk for their babies because of socio cultural
  reasons and religious beliefs (Ighogboja et al
  1995).
• Muslim women object to receiving milk from Hindu
  women
• Jewish women may request milk from a mother
  following a Kosher diet
• South African Mums?
• Neonatologists and Paeds?

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iThemba Lethu Breastmilk Bank
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Human Milk Banks in South Africa- KwaZulu Natal
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Baby M
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• Improvement was radical, dermatitis had
  resolved, gastroenteritis resolved, child was
  more alert and responsive, even the fisting had
  improved somewhat. This study was retrospective
  and there are poor records but if medical science
  can be considered both a science and an art, what
  breastmilk did for that baby is a masterpiece.
• Dr SA Biliman Dr Pather,
• Durban

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Baby T

• PCR positive, Mantoux positive
• Arrived at IL 8 months
• On breastmilk immediately
• TB treatment from Oct 06-May 07
• Then started on HAART treatment
• No repeated chest infections or diarrhoea-
  possibly due to the fact she has been on
  breastmilk for 14 months

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Baby Pieter

• Born at 28 weeks in W. Cape
• Birth weight 1 kg
• Mother had previous breast surgery so was unable
  to provide breast milk for her baby
• Couriered frozen breast milk down from iThemba
  Lethu
• Discharged after 2 mths weighing 2.1kg. Had no
  respiratory or other infections

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Baby S

• Born 20/11/02, BW 2.5 kg
• Arrived at IL 29/1/03
• Weight 3kg malnutrition, scabies, TB,
  respiratory distress and HIV pos.
• Mother and grandmother had full blown AIDS.
• Put on breastmilk. Gained weight despite
  respiratory infections and diarrhoea. He
  continued to receive the breast milk until he was
  14 mths old. At 21 months he started on HAART
  treatment and has thrived.

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King Edward Breast Milk Bank
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Western Cape Milk Matters

• Registered NPO and NGO
• Funding from UNICEF, Corporate, Public, Fuchs
  Foundation
• Charge for donor milk
• www.milkmatters.org
• Mowbray Maternity, Tygerberg, Groote Schuur
  Hospital, Panorama Mediclinic,
• Wynberg Military Hospital, N 1 City Hospital,
  Chris Barnard Memorial Hospital, Kingsbury
  Hospital, Paarl Mediclinic
• Recruit Donors from ANC Clinics, NICUs,
  Pharmacies, Libraries, talks at maternity
  hospitals on radio, magazines, newspapers.

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Mowbray Maternity
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SABR- Gauteng

• Pretoria Academic Hospital (PAH)Netcare Parklane
  'twinned' with BaragwanethNetcare Femina twinned
  with PAHN17 Springs twinned with Far East Rand
  HospitalNetcare Cuyler twinned with Dora Ingiza
  Hospital and ProvincialHospital
  UitenhageUNIVERSITAS Bloemfontein supported by a
  number of privates in the areaSABR Head office
  Johannesurg supplies the excess to the other
  hospital facilities that use but don't bank
  activelySandton Mediclinic twinned with Kalafong

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• Redistribute DBM to over 20 hospital facilities
  in and around Gauteng.
• o Netcare Feminao Netcare Sunninghillo Netcare
  Garden City o NetcareClinton
• o Netcare Parklane (Key donor) o Netcare
  Montana o Netcare Cuyler o Netcare Pretoria
  East o Netcare Unitas o N17 Springs o
  Universitas Bloemfontein (our latest) o Pretoria
  Accademic o Kalafong (Key Recipient)o
  Wilgeheuwel o Eugene Maree o Sandton Mediclinic
  (Key donor)o Clinics Soweto o Witbank Hospital
  (key recipient) o Medforum Pretoria

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SABR- Gauteng
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International Breast milk Project

• Jill Youse in USA breastfeeding baby and had
  excess milk- contacted iThemba Lethu early 2006
• Formed an NGO to send Breast milk to babies
  orphaned by HIV/AIDS
• April 2006 contacted us again to send milk- first
  2 boxes came with courier
• Next shipment sponsored by DHL arrived in May 06
• ABC filmed and was shown on Oprah around the
  world
• Further 5 shipments pasteurised and packed in
  individual bottles- stored in cold storage at
  Etlin

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International Breastmilk Project
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Current research regarding use of Donor Milk

• Most bioactive properties remain viable after
  pasteurisation
• Pasteurised donor milk for preterm and high risk
  infants reduces incidence of NEC, sepsis
  infection resulting in shorter stays in hospital
• Holder pasteurization reliably inactivates HIV
  and CMV and will eliminate titers of most other
  viruses( AAP,2000 Lawrence,1999).

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Storage of human milk and the influenceof
procedures on immunological components of human
milk. Lawrence RA. Acta Paediatr 1999.8814-18

• Summary
• Immunoprotective components of human milk are
  stable when stored at
• -room temperature for 8hrs
• -0-4C for 3 days
• -frozen at -20 C for 12 mths
• Stable after pasteurisation at 56 C x 30 min

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Heat treatment of Breastmilk

• Holder Method- 62.5 C for 30 min.

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Holder Method- Brazil
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HTST
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Thawed Milk being poured into tanks
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Filling bottles post pasteurisation
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Pretoria Pasteurisation

• Method uses passive transfer of heat from water
  heated to boiling point.
• Place 50-150 ml breastmilk into clean covered
  glass jar.
• Boil 450 ml water in small aluminum pot. Remove
  from heat source.
• Stand milk jar upright in pot of boiled water,
  cover the pot and leave for 15-20 min.
• Maintains milk between 56C and 62.5C for
  between 12-15 min.
• It effectively inactivates HIV in human milk
  kills commensal pathogenic bacteria
• (Jeffery et al J Trop Peds 2001)

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Flash Heating

• Use I litre aluminum pot with 450 ml of water and
  a 450 ml glass jar with a lid. Place between
  50-100ml of milk in the jar.
• Place uncovered jar of milk into the pot of water
  and heat it over heat source. Water level should
  be two fingers above the level of the milk.
• Once water boils, remove container of milk
  immediately from the pot and allow to cool

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Benefits of Heat Treated Human Milk

• Most bacteria, viruses and other pathogens are
  destroyed
• Facilitates action of epidermal growth factor and
  lysozyme
• Most enzymes, vitamins and minerals are unchanged
  or minimally decreased
• Many immunoglobulins and other infection fighting
  factors are unchanged or minimally decreased
• (Wight, N. 2005. Neonatalogist, President of
  Academy of B/f Medicine
• HMBANA Conference 2004)

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Effects of Heat treatment(Arnold
Larson1993Henderson, et al,1998)
Component 56 c x 30min (Pretoria Past.) 62.5 C x30 min.(Holder)
S . Aureus 100 killed 100 killed
E. Coli 100 killed 100 killed
Lactoferrin 72 retained 22 retained
IgA 84 retained 51 retained
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Effects of Heat treatment (LTU)
Component 56C X 30 min 62.5 C X 30 min
Lysozyme 100 retained 100 retained
Growth Factor stable stable
Long Chain- PU Fatty acids stable stable
Lipase destroyed destroyed
Amylase stable stable
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Percentage of activity remainingwww.latrobe.edu.a
u
Heat Treatment(15 secs.) Heat treatment(30 mins.) Heat treatment Refrigera- tion(7 days) Freezing(3 mths)
72C Flashheating 62.5C"Holder method 56C 4C -15C
Secretory IgA 85 70 85 100 100
IgM 0 Decreased
IgG 70 95 Decreased
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www.latrobe.edu.au
Oligosaccharide Heat treatment 15 sec. 100 56 C-30 min. 100 62.5 C-30 min. 100 Refridgeration (7days) 100 Freezing ( 3mths) 100
Bacterio-static activity (on added E. coli) Some decrease Some decrease No decrease Decrease at 1 mth, 66 present _at_ 3mths
Cytomega-lovirus Nil Nil Can be some Gone in ¼ samples in 24hrs, all gone by 7 days Gone in most samples after 24 hrs, others decrease by 99 in 3 days
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Percentage of activity remainingwww.latrobe.edu.a
u
Flash heating 72c-15 sec Holder method 62.5 C-30 min Pretoria Past. 56 C Refridge. 7 days 4C Freezing 3mths -15 C
Lactoferrin ( Iron binding capacity) 100 40 75 - 100
Lyzozyme Lipase ( generate anti-micro-bial lipids) 100 3 75 0 100 - 75 90 50
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Storage duration for Human Milk (HMBANA)
Human Milk Room Temp. Refrigerator Time in Freezer
Freshly expressed lt 4 hrs at 26 C lt 24 hrs at 15C ( cooler with gel packs) lt 8 days at 0-4 C ( bacterial contamination decreases over 8 days) Safe time 48 hrs UKAMB) lt 12 mths at -20C for preterm or ill infant ( 3 mths is optimal) 2wks in ice box
Previously frozen-thawed in fridge but not warmed lt 4 hrs lt 24 hrs Do not refreeze
Previously frozen milk brought to room temp. For completion of current feed 4 hrs Do not refreeze
Infant has started feeding Only for completion of feed then discard Discard Discard
Frozen donor milk Only for completion of feeding then discard lt 24 hrs Do not refreeze
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Donor Milk Banking in Health Policy

• Effective part of health care delivery for
  infants
• Preventative medicine in preterm population-
  prevent NEC optimizes CNS development
• BFHI- Step 1- Have a written policy that is
  routinely communicated to all health care staff
• Moms separated from their infants should be
  taught how to establish lactation policy
  relating to use of donor milk would fall under
  this step.
• Step 3- Inform all pregnant women about the
  benefits of and management of breastfeeding

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Donor Milk Banking Policy (cont.)

• Parents should be educate about the availability
  of donor milk its benefits
• Step 4- Initiation of b/f within first hour
• Banked donor milk should be given if Mothers
  own milk is not available
• Step 5- Show mothers how to breastfeed maintain
  lactation even if separated from their infants
• Mother should be helped to express and
  maintain a supply of b/m but can also be informed
  of the opportunity to become a donor if they have
  an ample supply

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• Step 6- Breastfed babies should receive no food
  or drink other than human milk unless there is a
  medical indication
• This is where donor milk fits in, NICU are
  responsible for using donor milk not formula

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Global Strategy for Infant and Young Child
Feeding 2003

• Section 18 The vast majority of mothers can
  and should breastfeed, just as the cast majority
  of infants can should be breastfed. Only under
  exceptional circumstances can a mothers milk be
  considered unsuitable for her infant. For those
  few health situations where infants cannot or
  should not be breastfed the choice of the best
  alternative- expressed breast milk from the
  infants own mother, breast milk from a healthy
  wet nurse or a human milk bank, or a breast milk
  substitute fed with a cup, which is safer method
  than a feeding bottle and teat- depend on
  individual circumstances ( pg 10).

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Whose responsibility is this strategy?

• Governments, health
  professionals, associations, NGO/s, community
  based support groups, commercial enterprises,
  employers ALL have responsibilities for making
  this strategy successful

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International Trends

• UK- UKAMB 1993- Guidelines endorsed by BPA
• Banks all over Europe, Australia China
• USA- HMBANA( 20th Anniversary)
• Brazil- (1981) operates under Ministry of Health
• seen dramatic drop in IM rates. 87.9 in 1980
  to 27.6 in 2007. Milk Banking has dramatically
  improved breastfeeding rates.( Avg. duration b/f
  increased 5.5 mths to 10 mths in 10 yrs).
• Almeida( 2001) Human milk banks have been one of
  the most important strategic elements in public
  policy favouring b/f in the last two decades in
  Brazil.

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Role of Human Milk Banking Association of
South Africa

• Government does not regulate milk banks under any
  specific legislation. So milk banks operating in
  SA must be committed to the highest standard of
  self-regulation
• Milk Banking should be an essential component
  of maternal and child health, especially for the
  preterm and sick infant
• Milk banks should operate on a non- profit basis
• Need for national guidelines provision of the
  gold standard for safe handling of human milk-
  based on international guidelines

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Vision for HMBASA

• HMBASA seeks to play an important role in
• Reducing mortality and morbidity in critically
  ill or premature infants
• Providing human milk when direct breastfeeding is
  not possible
• Providing human milk to babies orphaned by
  HIV/AIDS

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Objectives

• The provision of information and advice in all
  areas of human milk banking including best
  practice guidance
• The regular development , maintenance and
  updating of guidelines in accordance with any
  new research and clinical evidence
• The assistance as necessary with guidance in
  setting up new banks (note each bank to provide
  own funding and own committee and will operate
  autonomously)

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Management committee

• The Management Committee will consist of 10 20
  people and ideally have one or more
  representatives from each of the following
  constituencies
• Ministry of Health
• UNICEF
• Obstetricians
• Neonatologists
• Nutritionist/Public Health Scientist
• Lactation consultants
• Microbiologist/immunologist
• Public Relation specialist/Fund Raiser

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Conclusion

• As the public and medical professionals
  awareness about the benefits of using donor milk
  grows so will the demand for this precious
  commodity will grow
• So much to do, so many people to educate.

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When do we start?
Many of the things we need can wait. The
children cannot. To them we cannot answer
tomorrow. Their name is today. Gabriela Mistral,
Chile Nobel Prize for Literature, 1945
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Thank You!
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