The World Health Organization (WHO) and United Nations Children's Fund (UNICEF) recommend exclusive breastfeeding for the first 6 months of life and continued breastfeeding with safe and adequate complementary food for up to 2 years and beyond (WHO and UNICEF, 2018).
It is recognised that for term babies, additional milk supplementation may be necessary to support breastfeeding, as a result of medical indications or maternal request during the early postpartum period. Human milk banks provide donor human milk for human babies and operate according to guidelines developed by national bodies or local organisations (Shenker et al, 2021).
Currently, worldwide, donor human milk is reserved primarily for babies in the neonatal setting, preterm babies and critically ill babies (Shenker et al, 2021). Human milk should be offered as first option supplementation for all breastfed babies when additional maternal milk is required (WHO and UNICEF, 2018). The early introduction of commercial formula milk is associated with cessation of breastfeeding (Bond et al, 2021).
Despite the desirable scenario that donor human milk is available in all healthcare settings where care is provided to mothers and their babies, this is far from reality. In this article, the first author reflects on access to donor human milk in an Irish Regional Hospital. Gibb's (1988) reflective cycle has been used to learn from a real life situation in which donor human milk was not available for a term infant requiring supplementation for medical reasons during the early postpartum period. The pseudonyms ‘Elaine’ and ‘baby Tom’ were used to refer to the woman and her baby.
Case study
Elaine was admitted to the postnatal ward following the spontaneous vaginal birth of her firstborn, baby Tom. Elaine had an uncomplicated pregnancy, commenced spontaneous onset of labour and had an uncomplicated birth. Elaine wished to breastfeed.
Baby Tom weighed 4.1kg at birth with an Apgar score of 9 and 10 at 1 and 5 minutes after birth respectively. Baby Tom was placed immediately in skin‑to‑skin contact with his mother, and within a few minutes, he was seeking the breast, latching independently. A deep latch and good attachment were noted and he fed for nearly 1 hour between both breasts. During the feeding episode, rhythmic suckling was noted to be fair, no swallows were heard, and no milk was visible from the breast following hand expression. Additional support with breastfeeding was provided.
One hour post‑feed, Tom was awake and slightly jittery; therefore, a blood glucose level was taken, with a result recorded as 1.8mmol/L. Elaine and Baby Tom were supported to breastfeed again. The paediatric team on call were informed and a full infant consultation was completed. Baby Tom was admitted to the neonatal unit, as per the hospital guidelines. Manual hand expression of colostrum was commenced by Elaine with assistance from the midwife, to use as a supplement. Unfortunately, no colostrum was obtained, and so Elaine consented for her baby Tom to receive commercial milk formula for supplementation in the neonatal unit. Elaine was subsequently transferred to the maternity ward.
Description
Elaine was a postnatal mother on the maternity ward, in my care. Elaine wished to breastfeed her baby exclusively; however, following an episode of hypoglycaemia post‑birth, her baby received commercial formula milk. Elaine felt disappointed that she had consented to commercial formula milk supplementation, and she subsequently requested for her baby to receive donor human milk instead. I agreed to speak with the staff in the neonatal unit, who explained that in the regional hospital, donor human milk was not provided for any term baby, as there is no policy to regulate it.
I informed Elaine about the outcome of my conversation with the neonatal staff and she agreed to feed her baby with commercial formula milk if supplementation was required. A plan of action was established for the following 24‑hour period; Elaine would hand express colostrum every 3 hours while she was separated from her baby and would also visit the neonatal unit to stay close to her baby, with skin‑to‑skin contact as much as possible. Elaine would offer the breast regularly and supplement with commercial formula milk when medically indicated.
For the first 24 hours, baby Tom was mostly offered commercial formula milk when supplementation was indicated. Elaine only could obtain 1–2ml of colostrum in total by hand expression. A conversation with Elaine identified that she never received information on antenatal colostrum harvesting from 37 weeks’ gestation, and so could not provide extra expressed milk. Despite the challenges at this early postnatal stage, baby Tom latched to the breast for most feeds and received small quantities of expressed breast milk. However, the baby needed commercial formula milk top‑ups of 30–35ml to maintain adequate blood glucose levels.
Feelings
As a breastfeeding advocate, I was very disheartened for Elaine. Baby Tom was restricted from receiving donor human milk, despite his mother's wish to breastfeed and the well‑known recommendations that human milk should be prioritised when supplementation is needed (WHO and UNICEF, 2018). I felt frustrated both ethically and morally, as I was aware of the lack of availability of donor human milk in the hospital. I felt that we were not providing the best care because of the restricted access to donor human milk, especially as the maternity hospital is very supportive of breastfeeding. Healthcare professionals offering commercial formula milk is not supportive of exclusive breastfeeding, and this has been highlighted by the WHO (2015) as a cause of low breastfeeding rates.
Evaluation
Elaine was feeling guilty and emotional that her baby was receiving commercial formula milk. Her plan was to exclusively breastfeed. Emotional support was provided, and reassurance was given.
She was determined to breastfeed her baby. An individualised feeding plan was developed and Elaine was very thankful to the neonatal team and myself as we identified solutions to the breastfeeding challenges of the early postnatal period. The plan was in‑keeping with the Health Service Executive (2022) national standards for infant feeding in maternity services, whereby mothers are supported to breastfeed and then hand express at least eight times within 24 hours, in addition to safe skin‑to‑skin contact. At this stage, baby Tom was alert and feeding responsively. Hand expressing of colostrum is an essential tool to teach mothers to facilitate supplementation with their own milk, if this is required (Pollard, 2018).
I was disappointed that further efforts were not followed to obtain donor human milk for baby Tom. Additionally, Elaine had not been made aware of colostrum harvesting during the antenatal period. Antenatal colostrum harvesting can commence from 36 gestational weeks if there are no risks for preterm labour, multiple pregnancy, cervical incompetence or cervical sutures (Pollard, 2018). In the DAME study, it was found that antenatal colostrum harvesting by hand expressing twice a day from 36 gestational weeks in diabetic mothers with low‑risk pregnancy was an intervention of no harm that may increase the chances of exclusive breastfeeding and avoid commercial formula milk (Forster et al, 2017).
Analysis
The importance of breastfeeding for maternal and infant health is unrivalled. Breastfeeding supports infants’ health and offers a protective effect against developing asthma (Lodge et al, 2015; Miliku and Azad, 2018), obesity (Giugliani et al, 2015), type 2 diabetes in adulthood (Horta et al, 2015a), dental cavities (Tham et al, 2015) and infections such as acute otitis media (Bowatte et al, 2015), and also produce better results on intelligence tests (Horta et al, 2015b). Women who breastfeed also benefit, having a lower risk of developing type 2 diabetes or breast and ovarian cancer (Chowdhury et al, 2015) and a reduced body mass index postnatally (Mantzorou et al, 2022).
Donor human milk has been prioritised in neonatal units and is available to the most premature and ill babies (Shenker et al. 2021). Human milk should be available for all newborn infants when medically indicated. There are 15 human milk banks in the UK (European Milk Bank Association 2021), one located in Northern Ireland, which was opened in 2000. In 2022, the milk bank provided donor human milk for approximately 844 babies across Ireland (Western Health and Social Care Trust, 2023).
In 2017, the Hearts Milk Bank was opened as an independent human milk bank, the first of its kind in the UK. The Hearts Milk Bank's initial purpose was to provide donor human milk to hospitals with no human milk bank; however, because of the large number of donors, they could also provide donor human milk to families outside of the hospital (Griffin et al, 2022). The growth of this independent milk bank has been achieved in association with charitable activity, as part of the Human Milk Foundation (Griffin et al, 2022).
In 2019, the Human Milk Foundation developed a prioritising panel, with the advice of volunteer experts, to provide donor human milk to families both inside and outside of the hospital. In this regard, they established four pillars of prioritisation: infant vulnerability (babies in intensive care units are always prioritised), maternal breastfeeding, maternal psychological health and milk bank supply/logistics (Human Milk Foundation, 2023). In Canada, donor human milk can be obtained in some pharmacies, via prescription or by buying it without prescription (NorthernStar Mothers Milk Bank, 2023).
There is evidence to suggest that the use of donor human milk for supplementation can support achievement of successful breastfeeding compared with the use of formula supplementation (Shenker et al, 2021). In a study in the USA, 30 women were interviewed after their healthy newborns required supplementation; the parents reported that donor milk was seen as a temporary plan versus the use of commercial formula milk which, once used for supplementation, was seen mostly as a long‑term plan (Kair and Flaherman, 2017). The use of donor human milk in neonatal units has been reported to increase breastfeeding rates on discharge (Williams et al, 2016;Wilson et al, 2018) and at 6 months of age (Merjaneh et al, 2020).
There is a trend in the USA towards the use of donor milk for healthy term babies, when supplementation is required, with reported higher exclusive breastfeeding rates (Belfort et al, 2017; Sen et al, 2018). It is important that mothers and healthcare professionals are aware of the negative impact that supplementation with commercial formula milk causes to the breastfeeding relationship.
Additionally, the impact of donor human milk use on maternal mental health was researched by Shenker at al (2022), who reported that most mothers of babies receiving donor human milk reported that it had a positive impact on their mental and physical health, and general family wellbeing. The use of donor human milk acted as a motivation to continue breastfeeding as women worked on increasing their breastmilk supply (Shenker et al, 2022).
Should donor human milk be used for supplementation of term healthy infants instead of commercial formula milk when supplementation is medically indicated? Power et al (2019) identified that in the Republic of Ireland, 38 (86%) respondents (paediatricians and neonatologists) were opposed to the use of donor milk supplementation of otherwise healthy term neonates. In light of the success of the WHO ‘ten steps to successful breastfeeding’, donor human milk should be available for all newborn infants as it provides an equitable and supportive environment (WHO and UNICEF, 2018).
In the absence of donor human milk availability, colostrum harvesting is a feasible option. Antenatal milk expression after 37 weeks’ gestation has been shown as a safe tool to minimise the use of formula supplementation (Demirci et al, 2022). Forster et al (2017) offered the opinion that colostrum harvesting can commence at 36 weeks’ gestation for women with diabetes and low‑risk pregnancies. Antenatal colostrum harvesting has been described by women as empowering in a qualitative study (McGuinness et al, 2021) in which women with diabetes harvested colostrum in preparation for any breastfeeding challenges. Interestingly, the fact that commercial formula milk supplementation was less likely to be needed was highlighted by the women in this study (McGuinness et al, 2021).
Action plan
Further education in relation to antenatal colostrum harvesting is imperative in the maternity setting and is an important midwife‑led initiative. Antenatal colostrum harvesting is available for all low‑risk pregnant women after 37 weeks’ gestation at the authors’ hospital.
A policy and guideline are indicated to support supplementation with donor human milk for all newborn infants. The development of a human milk bank in the Republic of Ireland would be welcomed.
Conclusions
Further measures are needed to improve access to donor human milk in all maternity hospitals, including the development of evidence‑based policies. Antenatal colostrum harvesting can be encouraged when pregnant women express their wish to breastfeed and no contraindications are identified, in view of the restrictions on donor human milk at present in Irish and UK hospitals.
There is a lack of research on the use of donor human milk for healthy term babies to support exclusive breastmilk feeding. Further research is indicated, as breastfeeding mothers of healthy term babies may face delayed or low milk supply because of multiple clinical factors. The availability of donor human milk will support an enjoyable breastfeeding journey and early motherhood.