Human milk banks in Brazil

Developing global guidance on human milk banking

Donor human milk is recommended by the World Health Organization both for its advantageous nutritional and biological properties when mother’s own milk is not available and for its recognized support for lactation and breastfeeding when used appropriately. An increasing number of human milk banks are being established around the world, especially in low- and middle-income countries, to facilitate the collection, processing and distribution of donor human milk. In contrast to other medical products of human origin, however, there are no minimum quality, safety and ethical standards for donor human milk and no coordinating global body to inform national policies. We present the key issues impeding progress in human milk banking, including the lack of clear definitions or registries of products; issues around regulation, quality and safety; and ethical concerns about commercialization and potential exploitation of women. Recognizing that progress in human milk banking is limited by a lack of comparable evidence, we recommend further research in this field to fill the knowledge gaps and provide evidence-based guidance. We also highlight the need for optimal support for mothers to provide their own breastmilk and establish breastfeeding as soon as and wherever possible after birth.

Trace mineral composition of human breast milk from Brazilian mothers

BACKGROUND

Human milk is a dynamic food and some important differences in composition can be found between the milk from preterm and terms infants. Additionally, in some situations, the mother's own milk is unavailable and the use of milk from human milk banks is considered as the most appropriate substitute. In this way, concentrations of trace elements (Ba, Cu, Fe, Mn, Mo, Se, Sr, and Zn) were determined in human milk, considering the differences about preterm and term human milk and its processing in a human milk bank.

METHODS

A total of 156 samples were analyzed, which were divided in three groups: samples collected at the hospital at bedside (BS, 60 samples) from mothers of preterm infants and samples from mothers of term infants collected in a human milk bank without pasteurization (WP, 49 samples) and pasteurized by the Holder procedure (P, 47 samples). The analyzes were conducted by inductively coupled plasma mass spectrometry (ICP-MS) after the treatment of the samples with acid mineralization assisted by microwave radiation.

RESULTS

Concentrations varied in a range of 0.6-88.2 μg/L for Ba, 78.6-954.5 μg/L for Cu, 24.2-5229.2 μg/L for Fe, 0.4-42.6 μg/L for Mn, 0.1-39.1 μg/L for Mo, 2.5-70.6 μg/L for Se, 8.9-187.5 μg/L for Sr and 76.3-17727.2 μg/L for Zn. Significant differences (p < 0.05) were found between preterm (BS) and term human milk (WP and P) for Ba, Cu, Mo, Se, and Zn, whereas the processing of the donated milk by Holder pasteurization did not influence the concentration of the studied trace elements. The milk of term infants does not attend the recommended daily intake (RDI) of Zn and for preterm infants the RDI of Fe and Mn is not achieved.

CONCLUSIONS

The higher concentrations of Cu, Mo, Se and Zn observed in milk from mothers of preterm infants indicate that the milk to be offered for these high-risk neonates in neonatal intensive care units should contain higher levels of these trace elements. Besides, considering the RDI, the milk of term infants should be fortified with Zn, whereas the milk of preterm infants should be fortified with Fe.

The freeze-drying does not influence the proteomic profiles of human milk

Purpose: Human milk (HM) proteins are known as important factors in growing and development of neonates. For longer and easier storage of HM, freeze-drying is suggested as one of the promising methods for HM banks. However, the effects of freeze-drying on HM proteins were not evaluated yet. The purpose of this study is to analyze and compare proteomic data before and after the freeze-drying.Material and methods: Totally nine fresh HM samples were collected from three healthy mothers at 15 and 60 days of lactation period. The samples were freeze-dried and the proteomic analysis was performed by shotgun proteomic method with mass spectrometry. The results were compared between samples of different lactation periods, and before and after the freeze-drying using Wilcoxon signed-rank test for paired comparisons. Moreover, the functional grouping and analysis were performed for the detected proteins by bioinformatics analysis.Results: Totally, 245 proteins were detected in the HM samples. The expression of proteins was not affected by both of the different lactation periods and the freeze-drying status (P>.050). Moreover, the functional analysis of proteomic data revealed no significant difference between both groups as well.Conclusion: HM proteins were found not to be significantly affected by the lactation periods (15 and 60 days) and freeze-drying status. As significant changes of HM proteins were not found after the freeze-drying, we hope that the present study would support introducing freeze-drying in the HM banks. However, the number of samples was quite small to provide strong evidence. Moreover, the evaluation of the safe storage length in the view of infectious agents and the composition changes after freeze-drying is warranted in the further study.

Establishing an integrated human milk banking approach to strengthen newborn care

The provision of donor human milk can significantly reduce morbidity and mortality among vulnerable infants and is recommended by the World Health Organization as the next best option when a mother's own milk is unavailable. Regulated human milk banks can meet this need, however, scale-up has been hindered by the absence of an appropriate model for resource-limited settings and a lack of policy support for human milk banks and for the operational procedures supporting them. To reduce infant mortality, human milk banking systems need to be scaled up and integrated with other components of newborn care. This article draws on current guidelines and best practices from human milk banks to offer a compilation of universal requirements that provide a foundation for an integrated model of newborn care that is appropriate for low- and high-resource settings alike.

A mixed-methods observational study of human milk sharing communities on Facebook

OBJECTIVES

The Food and Drug Administration discourages the casual sharing of human milk because of the risk of pathogen transmission. No information is currently available on the prevalence of this practice. The purpose of this mixed-methods observational study is to describe the size and activity of online milk sharing communities.

MATERIALS AND METHODS

Data for 3 months were extracted from nine public Facebook pages that facilitate the exchange of human milk. The numbers of participants, interactions, and comments were analyzed.

RESULTS

We observed 954 individuals participating in milk sharing. The number of interactions per individual ranged from none to 16 (mean, 1.74 ± 1.65). Top reasons that participants requested milk included "lactation problems" (69.4%) and "child health problems" (48.5%). Nearly half of donors were offering 100 ounces or more, which is the minimum to be eligible to donate to nonprofit milk banks.

CONCLUSIONS

Milk sharing networks in the United States are active, with thousands of individuals participating in the direct exchange of raw human milk. Public health issues include increasing the supply of pasteurized donor milk for fragile infants, increasing breastfeeding support, and helping milk sharing families appropriately manage risks.

Effect of Holder pasteurization and frozen storage on macronutrients and energy content of breast milk

OBJECTIVES

The aim of this study was to explore the effect of Holder pasteurization and frozen storage at -20°C after pasteurization on fat, total nitrogen, lactose, and energy content of breast milk. Both procedures are routinely practiced in human milk banks.

METHODS

A total of 34 samples of frozen breast milk, donated by 28 women, were collected. Once thawed, an aliquot of each sample was analyzed before pasteurization; the remaining milk was pasteurized (Holder method) and split into 8 aliquots. One aliquot was analyzed after pasteurization and the remainder frozen at -20°C and analyzed 30, 60, 90, 120, and 180 days later. For every aliquot, fat, total nitrogen, lactose, and energy content were determined using the device human Milk Analyzer.

RESULTS

We observed a significant reduction in fat (3.5%; -0.17 (-0.29; -0.04) g/dL) and energy content (2.8%; -2.03 (-3.60; -0.46) g/dL) after pasteurization. A significant decrease over time was observed for fat, lactose and energy content. No significant changes were observed for nitrogen content. Mean differences between day 0 postpasteurization and day 180 were -0.13 (-0.21; -0.06) g/dL for fat, -0.08 (-0.13; -0.03) g/dL for lactose, and -1.55 (-2.38; -0.71) kcal/dL for energy content. The relative decreases were 2.8%, 1.7%, and 2.2%, respectively. Overall (postpasteurization + frozen storage), a 6.2% and 5% decrease were observed for fat and energy, respectively.

CONCLUSIONS

Holder pasteurization decreased fat and energy content of human milk. Frozen storage at -20°C of pasteurized milk significantly reduced fat, lactose, and energy content of human milk.

Effect of freezing time on macronutrients and energy content of breastmilk

BACKGROUND

In neonatal units and human milk banks freezing breastmilk at less than -20 °C is the choice for preserving it. Scientific evidence in relation to the loss of nutritional quality during freezing is rare. Our main aim in this study is to determine the effect of freezing time up to 3 months on the content of fat, total nitrogen, lactose, and energy. Our secondary aim is to assess whether ultrasonic homogenization of samples enables a more suitable reading of breastmilk macronutrients with a human milk analyzer (HMA) (MIRIS, Uppsala, Sweden).

METHODS

Refrigerated breastmilk samples were collected. Each sample was divided into six pairs of aliquots. One pair was analyzed on day 0, and the remaining pairs were frozen and analyzed, one each at 7, 15, 30, 60, and 90 days later. For each pair, one aliquot was homogenized by stirring, and the other by applying ultrasound. Samples were analyzed with the HMA.

RESULTS

By 3 months from freezing with the two homogenization methods, we observed a relevant and significant decline in the concentration of fat and energy content. The modification of total nitrogen and lactose was not constant and of lower magnitude. The absolute concentration of all macronutrients and calories was greater with ultrasonic homogenization.

CONCLUSIONS

After 3 months from freezing at -20 °C, an important decrease in fat and caloric content is observed. Correct homogenization is fundamental for correct nutritional analysis.

Acceptability of donated breast milk in a resource limited South African setting

Background

The importance of breast milk for infants' growth, development and overall health is widely recognized. In situations where women are not able to provide their infants with sufficient amounts of their own breast milk, donor breast milk is the next preferred option. Although there is considerable research on the safety and scientific aspects of donor milk, and the motivations and experiences of donors, there is limited research addressing the attitudes and experiences of the women and families whose infants receive this milk. This study therefore examined attitudes towards donated breast milk among mothers, families and healthcare providers of potential recipient infants.

Methods

The study was conducted at a public hospital and nearby clinic in Durban, South Africa. The qualitative data was derived from eight focus group discussions which included four groups with mothers; one with male partners; and one with grandmothers, investigating attitudes towards receiving donated breast milk for infants. There was also one group each with nurses and doctors about their attitudes towards donated breast milk and its use in the hospital. The focus groups were conducted in September and October 2009 and each group had between four and eleven participants, leading to a total of 48 participants.

Results

Although breast milk was seen as important to child health there were concerns about undermining of breast milk because of concerns about HIV and marketing and promotion of formula milks. In addition there were concerns about the safety of donor breast milk and discomfort about using another mother's milk. Participants believed that education on the importance of breast milk and transparency on the processes involved in sourcing and preparing donor milk would improve the acceptability.

Conclusions

This study has shown that there are obstacles to the acceptability of donor milk, mainly stemming from lack of awareness/familiarity with the processes around donor breast milk and that these could be readily addressed through education. Even the more psychological concerns would also likely be reduced over time as these educational efforts progress. With government and health care worker endorsement and commitment, breast milk donation could have a promising role in improving child health.

Antimicrobial-resistance and enterotoxin-encoding genes among staphylococci isolated from expressed human breast milk

Resistance traits and the presence of enterotoxin-encoding genes were investigated in staphylococcus isolates obtained from expressed human breast milk. A total of 54 staphylococcal isolates identified as Staphylococcus epidermidis (53.6 %), Staphylococcus warneri (20.4 %), Staphylococcus haemolyticus (13 %) and Staphylococcus aureus (13 %) were investigated. By using a disc-diffusion method, higher rates of resistance, including intermediate resistance, were observed for penicillin (87 %) and erythromycin (59.3 %). All strains were susceptible to clindamycin and vancomycin. Minimal inhibitory concentration (MIC) was determined by a macrodilution method for four clinically relevant antimicrobial drugs. High rates of resistance or intermediate resistance were observed for erythromycin, gentamicin and oxacillin. Additionally, three isolates showed reduced susceptibility to vancomycin (MIC, 8 microg ml(-1)). Genetic determinants of resistance were detected by using PCR and the results showed good correlation with the macrodilution tests. Moreover, in four staphylococcus isolates, the presence of enterotoxin-encoding genes (seg, seh and sea) was identified. The results demonstrated that expressed human breast milk can be a reservoir of multiresistant staphylococci that may also harbour important virulent determinants.

HIV transmission through breastfeeding: problems and prevention

The greatest burden of HIV infection in women and their children is disproportionately borne by the poorest countries, especially in sub-Saharan Africa. Breastfeeding is a major health-promoting factor for infants and children in developing countries but the risk of mother-to-child transmission (MTCT) of HIV by this route is challenging traditional practices and health policies in low-resource countries. Maternal and infant factors contributing to the risk of MTCT through breastfeeding are still poorly understood and not well researched. Factors identified include: advanced clinical stages of infection in the mother; high maternal plasma HIV-1 load; presence of mastitis; and infant oral thrush. In many developing countries, international agencies are providing support and recommendations for preventing MTCT of HIV-1 by breastfeeding. Preventive strategies supported by WHO/UNICEF and charitable agencies in some sentinel centres in sub-Saharan Africa include routine antenatal voluntary counselling and testing (VCT), PCR testing of infants of seropositive mothers at 6 weeks of age, various combinations of a shortened period (3-6 mths) of exclusive breastfeeding, perinatal administration of antiretrovirals (ARV) such as nevirapine and provision of affordable and safe infant replacement feeds (presently given free by UNICEF in some centres). Many problems, however, have hindered effective implementation of these interventions. In many poor communities, even where VCT facilities are available, acceptance of HIV testing is low because there is fear of stigmatisation by the spouse, family or community and compliance with complex drug regimens is therefore poor. Other problems include the exorbitant cost of antiretroviral drugs, inadequately resourced health care systems and unavailability or poor acceptance of safe breast-milk alternatives. The rate of mixed feeding is high and so the risk of MTCT is increased. Continued promotion of exclusive breastfeeding for at least 6 months, irrespective of HIV status, followed by a properly prepared, high energy, nutritious complementary diet, with the possibility of early weaning to an animal milk formula, still appears to be the most appropriate option for the poor in countries with high levels of MTCT not deriving any benefit from the above strategies. While a longer period of breastfeeding would probably increase the risk of MTCT in vulnerable communities, a shorter duration would certainly increase infant morbidity and mortality. Results of investigations of the efficacy of ARV for protecting the infants of HIV-infected mothers during the breastfeeding period are awaited.

Donor milk: what's in it and what's not

Breastfeeding and human milk are widely recognized as optimal for human infants. However, if donor milk is used when mother's own milk is not available, some questions arise concerning the effects of storage, handling, and heat processing on the unique components of human milk. Holder pasteurization (62.5 degrees C for 30 minutes) of banked human milk is the method of choice to eliminate potential viral contaminants such as human immunodeficiency virus, human T-lymphoma virus, and cytomegalovirus, as well as tuberculosis and other bacterial contaminants, while maintaining the greatest possible complement of its unique bioactive factors. This article reviews some of the critical components of human milk and what is currently known about the effects of Holder pasteurization on their biological activity.

Excelência em bancos de leite humano: uma visão do futuro--the First International Congress on Human Milk Banking

The first International Congress of Human Milk Banks--Excellence in Human Milk Banking: A Vision of the Future, held in Brazil in June 2000 and sponsored by the Brazilian Association of Milk Banks, had representation from milk banks in Argentina, Chile, Costa Rica, Venezuela, France, the United Kingdom, and North America as well as Brazil. A recurring theme in the discussion of donor milk banking was the role of each country's milk banks in the promotion and support of breastfeeding. The Brazilian National Reference Milk Bank and the growth of donor milk banking in Brazil over the past 15 years were described, including federal regulation that all milk bank directors be trained and certified. Milk banking systems in France, the United Kingdom, Venezuela and the Caribbean, and North America were also discussed. Similarities and differences in the donor screening process and the regulation of milk banks in the countries is presented.