Prevalence and predictors of donor milk programs among U.S. advanced neonatal care facilities

Conceptualizing the Commercialization of Human Milk: A Concept Analysis

BACKGROUND

Donor human milk is recommended when infants are unable to be fed their mother's own milk or require supplementation. For-profit companies use technologies to create human milk products for infants in the neonatal intensive care setting without consistent guidelines and regulatory frameworks in place. This commercialization of human milk is inadequately conceptualized and ill-defined.

RESEARCH AIMS

The aim of this study is to conceptualize and define the commercialization of human milk and discuss the need for policy guidelines and regulations.

METHOD

Using a concept analysis framework, we reviewed the literature on the commercialization of human milk, analyzed the antecedents and potential consequences of the industry, and developed a conceptual definition. The literature review resulted in 13 relevant articles.

RESULTS

There has been a surge in the development and availability of human milk products for vulnerable infants developed by for-profit companies. Commercialized human milk can be defined as the packaging and sale of human milk and human milk components for financial gain. Factors contributing to the commercialization of human milk include an increased demand for human milk, and consequences include potential undermining of breastfeeding. The lack of guidelines and regulations raises concerns of equity, ethics, and safety.

CONCLUSION

The industry is rapidly growing, resulting in an urgent need for consistent guidelines and regulatory frameworks. If left unaddressed, there could be potential risks for donor milk banking, the future of breastfeeding, and infant and maternal health.

Nutritional Strategies for Preterm Neonates and Preterm Neonates Undergoing Surgery: New Insights for Practice and Wrong Beliefs to Uproot

The nutrition of preterm infants remains contaminated by wrong beliefs that reflect inexactitudes and perpetuate old practices. In this narrative review, we report current evidence in preterm neonates and in preterm neonates undergoing surgery. Convictions that necrotizing enterocolitis is reduced by the delay in introducing enteral feeding, a slow advancement in enteral feeds, and the systematic control of residual gastric volumes, should be abandoned. On the contrary, these practices prolong the time to reach full enteral feeding. The length of parenteral nutrition should be as short as possible to reduce the infectious risk. Intrauterine growth restriction, hemodynamic and respiratory instability, and patent ductus arteriosus should be considered in advancing enteral feeds, but they must not translate into prolonged fasting, which can be equally dangerous. Clinicians should also keep in mind the risk of refeeding syndrome in case of high amino acid intake and inadequate electrolyte supply, closely monitoring them. Conversely, when preterm infants undergo surgery, nutritional strategies are still based on retrospective studies and opinions rather than on randomized controlled trials. Finally, this review also highlights how the use of adequately fortified human milk is strongly recommended, as it offers unique benefits for immune and gastrointestinal health and neurodevelopmental outcomes.

Comparison of Breastfeeding and Pumping Experiences of Milk Bank Donors in the United States and United Kingdom

Background/Objective: As human milk banking services expand, information about lifestyle characteristics and infant feeding experiences of milk bank donors is relatively limited. Our goal was to describe and compare milk bank donors' demographic, clinical, and lifestyle characteristics, and breastfeeding experiences in a variety of geographic settings. Methods: A cross-sectional online survey was conducted from August 2022 to December 2022 with approved donors from three milk banks in the United States (n = 369), and one milk bank in United Kingdom (n = 187). Results: Donors in all settings were predominantly in their early 30s, White, married, educated, and identified as female. U.K. donors reported more frequently being on maternity leave (33% versus 5%, p < 0.001), predominantly feeding directly at the breast in the first 3 months postpartum (51% versus 28%, p < 0.001), and breastfeeding a single child longer (21.2 versus 13.3 months, p < 0.001) than U.S. donors. Significantly more U.S. donors reported pumping due to work (34% versus 11%, p < 0.001) and pumping multiple times per day (57% versus 36%, p < 0.001). Most donors reported receiving information about breastfeeding from a health care provider (94% United States and 88% United Kingdom, p = 0.022), while the internet was the most popular source of information about pumping (65% United States and 64% United Kingdom, p = 0.751). Conclusion: Factors not directly related to milk banking (e.g., maternity leave, sources of breastfeeding/pumping assistance) may have an impact on how donors feed their children and ultimately on their milk donation pattern. The impact of donor characteristics and feeding practices on donation patterns warrants further investigation.

Importance of human milk for infants in the clinical setting: Updates and mechanistic links

INTRODUCTION

Human milk (HM) is the optimal source of nutrition for infants and has been implicated in multiple aspects of infant health. Although much of the existing literature has focused on the individual components that drive its nutrition content, examining HM as a biological system is needed for meaningful advancement of the field. Investigation of the nonnutritive bioactive components of HM and the maternal, infant, and environmental factors which affect these bioactives is important to better understand the importance of HM provision to infants. This information may inform care of clinical populations or infants who are critically ill, hospitalized, or who have chronic diseases and may benefit most from receiving HM.

METHODS

In this narrative review, we reviewed literature examining maternal and infant influences on HM composition with a focus on studies published in the last 10 years that were applicable to clinical populations.

RESULTS

We found multiple studies examining HM components implicated in infant immune and gut health and neurodevelopment. Additional work is needed to understand how donor milk and formula may be used in situations of inadequate maternal HM. Furthermore, a better understanding of how maternal factors such as maternal genetics and metabolic health influence milk composition is needed.

CONCLUSION

In this review, we affirm the importance of HM for all infants, especially clinical populations. An understanding of how HM composition is modulated by maternal and environmental factors is important to progress the field forward with respect to mechanistic links between HM biology and infant health outcomes.

Medicaid and newborn care: challenges and opportunities

Since its creation in 1965, Medicaid has operated as a federal-state partnership that provides a robust set of medical benefits to low-income families, including pregnant people and infants. In many ways, Medicaid has met its initial promise. However, medical benefits, provider payments, and key administrative procedures regarding eligibility, enrollment, and access to care vary substantially among state Medicaid programs. These variations have created profound inequities across states in the care of parents and children, particularly during pregnancy and in the postpartum and neonatal periods. Here we review select aspects of the Medicaid program pertinent to newborns and infants that contribute to eligibility and enrollment gaps, variations in benefits coverage and payment rates, and racial disparities in both access to healthcare and infant health outcomes. We outline a number of structural reforms of the Medicaid program that can improve newborn and infant access to care and outcomes and redress existing inequities.

The Effects of Refrigerated Storage of Donor Human Milk with Limited Bacterial Presence After Holder Pasteurization on Nutrient Concentration and Bacterial Growth

Background: The Human Milk Banking Association of North America (HMBANA) sets the purity and quality standards for donor human milk (DHM) in the United States, which includes zero bacterial presence after Holder pasteurization. This study aimed to determine if nutrient and bacterial composition of DHM with limited bacterial presence after pasteurization change over 4 days of refrigerated storage. Methods: Twenty-five unique samples of DHM with limited bacterial growth postpasteurization were collected from two HMBANA milk banks. Infant formula was used as a comparison. Samples were stored in the refrigerator and a portion of milk was removed at 24-hour intervals beginning at hour 0 to 96 for analysis. Aerobic bacteria, protein, lactose, and immunoglobulin A (IgA) content were measured. Longitudinal changes between 0 and 96 hours were analyzed using repeated measures analysis of variance and mixed models test. p < 0.05 was deemed significant. Results: There was no significant difference in lactose, protein, bacteria, or IgA content over storage duration (p = 0.649, p = 0.690, and p = 0.385, p = 0.805, respectively). Total aerobic bacteria were less than 10² colony-forming units (CFUs) in 81% of the time points tested for DHM samples. Total aerobic bacteria were too many to count (>300 CFUs) in the infant formula sample at all time points. Conclusion: In periods of high demand for DHM, DHM with low bacteria growth postpasteurization may be an option as a supplemental food for the growing number of healthy infants who receive DHM. Future studies should investigate the bacterial strains in this milk.

US state policies for Medicaid coverage of donor human milk

Donor human milk is recommended by the American Academy of Pediatrics for high-risk infants when mother's own milk is absent or insufficient in quantity. Several factors may contribute to the inequitable use of or access to donor human milk, including a limited knowledge of its effects, cost, reimbursement, and regulatory barriers. The American Academy of Pediatrics and the United States Surgeon General have called for investigating barriers that prevent use of donor human milk for high-risk infants and for changes to public policy known to improve availability and affordability. We review the current legislative, regulatory, and economic landscape surrounding donor human milk use in the United States, as well as suggest state- and federal-level solutions to increase access to donor human milk.

Cytotoxic Lactalbumin-Oleic Acid Complexes in the Human Milk Diet of Preterm Infants

Frozen storage is necessary to preserve expressed human milk for critically ill and very preterm infants. Milk pasteurization is essential for donor milk given to this special population. Due to these storage and processing conditions, subtle changes occur in milk nutrients. These changes may have clinical implications. Potentially, bioactive complexes of unknown significance could be found in human milk given to preterm infants. One such complex, a cytotoxic α-lactalbumin-oleic acid complex named "HAMLET," (Human Alpha-Lactalbumin Made Lethal to Tumor cells) is a folding variant of alpha-lactalbumin that is bound to oleic acid. This complex, isolated from human milk casein, has specific toxicity to both carcinogenic cell lines and immature non-transformed cells. Both HAMLET and free oleic acid trigger similar apoptotic mechanisms in tissue and stimulate inflammation via the NF-κB and MAPK p38 signaling pathways. This protein-lipid complex could potentially trigger various inflammatory pathways with unknown consequences, especially in immature intestinal tissues. The very preterm population is dependent on human milk as a medicinal and broadly bioactive nutriment. Therefore, HAMLET's possible presence and bioactive role in milk should be addressed in neonatal research. Through a pediatric lens, HAMLET's discovery, formation and bioactive benefits will be reviewed.

Outcomes improved with human milk intake in preterm and full-term infants

This review highlights clinical outcomes of human milk from infancy through adulthood. Human milk outcomes of both preterm and term infants, including critically ill term infants (such as infants with congenital heart disease and those requiring therapeutic hypothermia) are summarized. Several human milk diets are identified to reduce the risk of specific diseases. Emerging research of newly discovered components of human milk are also reviewed. Human milk has significant effects on the gut microbiome, somatic growth, and neurocognitive outcomes. Continued research promises to improve donor human milk and donor milk derived products to achieve better outcomes for infants who do not receive their own mother's milk. The promotion of human milk is well-founded on evidence from the previous half century.

Donor Human Milk Use in Populations Other than the Preterm Infant: A Systematic Scoping Review

Introduction: Exclusive breastfeeding is recommended for an infant's first 6 months of life. If unable to breastfeed, expressed breast milk, including donor human milk (DHM), is recommended for optimal nutrition. Benefits of DHM in preterm infants have been established by extensive research. However, less is known about DHM use in other populations. Objective: To conduct a scoping review of the literature regarding DHM use in populations other than preterm infants. Materials and Methods: PubMed and Clinicaltrials.gov were used to search for articles and clinical trials published between January 1, 2000 and February 29, 2020. In total, 182 articles and reports were identified and screened by 2 independent reviewers. Results: Twenty-six articles met inclusion criteria and were reviewed. Studies were mostly observational in design and included infants born >35 weeks gestational age with health risks (9/26) and healthy infants (14/26). Most studies in infants with health risks (7/9) investigated clinical outcomes, with small, observational studies suggesting potential improvements in feeding tolerance and gastrointestinal health. Regarding healthy infants, no studies addressed growth, only one study measured clinical outcomes, and findings related to breastfeeding outcomes were conflicting. Over half of the studies reviewed (15/26) were not designed to establish a potential relationship between DHM use and relevant health-related outcomes. Conclusion: The current evidence of DHM use in populations other than preterm infants is limited by lack of direct health measures and infrequent use of randomized trials. More research is warranted to investigate clinical, growth, and breastfeeding outcomes.

National Prevalence of Donor Milk Use Among Level 1 Nurseries

BACKGROUND AND OBJECTIVES

Donor milk use has increased among very preterm infants because of mounting evidence of health benefits; however, the extent that donor milk is used among healthy term infants in level 1 nurseries is unclear. We aimed to determine (1) national prevalence of and (2) hospital factors associated with donor milk use in level 1 nurseries.

METHODS

Among 3040 US birthing hospitals, we randomly selected hospitals from each of 4 US regions (119 in northeast, 120 in Midwest, 116 in west, and 103 in south) for a total of 458 hospitals. We surveyed the nursing leaders of these hospitals from October to December 2017 regarding routine use of donor milk in the level 1 nursery (yes or no). To estimate national prevalence, we weighted responses according to the number of birthing hospitals within each region. We examined relationships between routine donor milk use in the level 1 nursery and hospital characteristics using multivariable logistic regression.

RESULTS

In total, 214 of 458 (47%) nursing leaders responded. The national prevalence of routine donor milk use in level 1 nurseries was 17.6%. Eighty-five percent of donor milk programs were ≤5 years old. Donor milk use occurred more often in hospitals with ≥1500 annual births (41.7%), compared to ≤500 annual births (6.3%) (adjusted odds ratio 7.8; 95% confidence interval 1.8-34.4), and in the west (30.9%), compared to the northeast (10.5%) (adjusted odds ratio 4.1; 95% confidence interval [1.1-14.9]).

CONCLUSIONS

Although there is limited evidence to support donor milk for healthy infants in the nursery, nearly one-fifth of level 1 US nurseries routinely used donor milk in 2017.

Human milk fortification: the clinician and parent perspectives

This study reports on the human milk fortification session at the 2019 NEC Society Symposium, which included clinicians and parents discussing the evidence comparing fortification options such as efficacy, safety, cost effectiveness, and the need for parents to be informed about fortifier choice. With the current literature available and the varying standard of care practices for human milk fortification, further studies are needed to determine the most complete diet for preterm infants. The optimal diet would not only provide key nutrients and energy for growth and development, but also improve short- and long-term outcomes. Parents, as advocates and providers for their infant, should be informed, educated, and included in the discussion and decisions regarding fortification of human milk for their infant.