Donor breast milk or formula feeding? Information is your key to informed choices

Many women in developed countries like the US find that despite their best efforts, they are unable to exclusively breastfeed due to supply problems or other circumstances. They may feel pressured into finding some other way of ensuring their babies are exclusively breastfed, even though they cannot produce enough for baby. Adoptive parents may also feel pressure to provide breast milk.

A lot of this pressure to provide breast milk comes from the over-exaggeration or misinterpretation of the benefits of breast milk on long-term health outcomes, or from unfounded fears about infant formula. Currently, there are two types of donor breast milk available to moms in the US, but only one type that is supported and recommended by major medical bodies like the American Academy of Pediatrics and by the Fed is Best Foundation.

Donor milk obtained from a milk bank or hospital is a safe and healthy alternative to mom’s own milk. Milk banks thoroughly screen their donor moms to ensure the safety of the milk and pasteurise it following strict food safety protocols to destroy bacteria that can make infants very ill. Milk banks are similar to blood banks. These organisations are designed to make sure human body fluids, whether breast milk or blood products, are screened and safe before they are used by vulnerable people like newborns and sick patients. This is because human body fluids, including breast milk, can pass transmissible infections like HIV from person to person.

Unfortunately, due to their rigorous safety procedures and the costly and time-intensive effort of screening and pasteurising the donor breast milk, the majority of moms in the US do not have access to safe, screened donor milk through a milk bank.

While breast milk from a milk bank is a safe and healthy food source, it is unlikely to be a viable option for most families due to limited availability and cost. For those families that are fortunate enough to have access to screened milk through a milk bank and also have the financial resources to support the ongoing expense, they may decide that choosing this nutrition source is their preference over infant formula. These parents should, however, be aware of the variable nature of donor milk supplies, and they should be prepared for the possibility that they will need to use formula at some point due to milk banks’ varying reserves of donor milk.

Due to the lack of safe donor milk provided by milk banks and hospitals, some parents are turning to unscreened peer-to-peer milk donations or sales facilitated over the internet. This is the second type of donor milk that is available. The AAP and the Fed is Best Foundation do NOT recommend that parents feed their children peer-to-peer milk obtained through informal donations, sales, or milk sharing websites. This is because there are growing safety concerns posed by offering unscreened and unregulated breast milk to infants.

Parents should not confuse the general breastfeeding guidelines put forward by organisations like the WHO and AAP with a tacit endorsement of peer-to-peer donor milk sharing in countries like the US – they are not. To date, the AAP explicitly discourages feeding infants unscreened peer to peer donor milk purchased or obtained via informal donations over the internet. Currently, no major medical organisation endorses, encourages or recommends the practice of sharing unscreened breast milk in developed nations where safe infant formula is available.

Safety concerns surrounding peer-to-peer milk donation and sales

Both peer-to-peer donations, as well as for-profit breast milk sales over the internet have been found to raise serious safety concerns. Research has demonstrated that some milk banks are still seeing significant incidence of potential donor moms with positive blood tests for conditions including HIV, syphilis and hepatitis. Without access to rigorous screening services, a small but significant percentage of infected mothers are at risk of sharing their breast milk with other families over informal milk sharing websites. In addition, recreational drugs, herbal supplements and various prescription medications have all been found to be present in breast milk, and some of these substances have potential adverse effects.

In a milk bank or hospital, many of these substances, including popular herbal remedies for milk supply, disqualify a mother from donation. The milk banks can ensure their milk is free of various substances, but due to the very high prevalence of recreational and prescription drug usage in the general public, breast milk containing elements of numerous drugs is inevitably circulating in informal milk-sharing networks. Given the highly publicised and optimistic assertions about various herbal remedies for milk supply, it is also likely that herbal supplement usage, in particular, may be high among informal donations.

In terms of food safety, a 2017 study on peer-to-peer donors discovered that while the majority of informal donors did make an admirable and conscious effort to handle and store their milk appropriately, the majority of them still did not follow at least four of the five food safety and handling steps necessary to ensure the safety of their donations. Furthermore, a recent article published by clinicians at a paediatric hospital explored two cases of medically complex infants who were subsequently found to be using unscreened, unpasteurised peer-to-peer donated breast milk obtained by their parents. For more information on the milk bank process, please visit http://www.hmbasa.org.za/ or https://www.sabr.org.za/

These cases suggest that even highly vulnerable, medically fragile infants may also be experiencing exposure to unscreened and unpasteurised breast milk from unknown sources, potentially without their clinical team’s knowledge. Sadly, the devastating effects of bacterially contaminated breast milk came into sharp focus recently in 2016, when a preterm infant died from chronobacter infection believed to be caused by contamination of the mother’s breast pump and the surrounding area used to clean the pump parts. This case verified that contaminated breast milk can have tragic consequences for vulnerable newborns and their families.

The data on for-profit breast milk sales is also concerning. A study published in Pediatrics in 2013 found that a whopping 75% of the milk samples purchased over the internet were contaminated with bacteria. A follow-up study in 2015 found that approximately 10% of samples of breast milk sold over the internet were potentially watered down with cow’s milk. Many peer-to-peer donation advocates claim that there is a significant difference between the kind of people who sell milk and those who donate informally, and so the data on breast milk sales does not apply to them and their version of milk sharing. The implication here is that only “good” or “healthy” people informally donate and therefore their donations should be viewed as automatically safe, based predominantly on the perceived moral character of the donor. However, as we have seen, safety concerns still exist in the well-intentioned informal donations, even without the presence of unscrupulous sellers looking to make a quick buck.

Peer-to-peer milk-sharing websites and informal donor moms certainly have the best intentions, but even the most well-meaning donor mom can accidentally contaminate her milk with microscopic bacteria while handling it, and some moms with transmissible infections like HIV may not know they are infected. Furthermore, few members of the lay public have formal training inappropriate handling and storage of human body fluids to prevent contamination, leading to purely unintentional missteps in food safety procedures.

Contaminated food sources can be dangerous for even full-term healthy infants, and the risk is heightened for preterm or medically fragile infants, who are already under substantial physiologic stress. Unfortunately, good intentions don’t make up for basic public health safety precautions.

Conclusions

Screened and pasteurised breast milk obtained from a legitimate source like a milk bank or hospital is a safe and potentially beneficial food source for infants – particularly the preterm population. However, this resource is currently very limited and most families will not have access to this nutrition source for their infants unless there is a documented medical need. While breast milk is wonderful, its potential benefits are not so important or so life-defining that it is worth risking your child’s immediate safety by exposing them to breast milk obtained from questionable or unknown sources. If you live in a developed nation like the US and you cannot produce enough milk or access a milk bank, the major medical organisations are clear – your safest and recommended infant feeding choice is commercially available infant formula.

Disclaimer: Breast milk is the best food for infants. Good maternal nutrition is essential to prepare and maintain breastfeeding. If breastfeeding is not applied, an infant formula may be used according to the advice of a health professional. Preparation and storage of any infant formula should be performed as directed on the tin in order not to pose any health hazards.