Use of Donor Human Milk in Premature Infants

                My last blog post discussed why breastfeeding is so important to an infant and how medications can play a role in a woman’s choice to breastfeed. Today is going to discuss the use of donor human milk in premature infants and how medications play a role here.

                Premature infants are a unique patient population.  We know that breastfeeding has many benefits for all infants, premature infants seem to gain even more benefits from this form of nutrition. Preemies, especially very low birth weight infants, are at increased risk for complications such as necrotizing enterocolitis, feeding intolerance, sepsis, and developmental delays. The American Academy of Pediatrics states that “The potent benefits of human milk are such that all preterm infants should receive human milk.” (Landers)

                With this knowledge, one would think that breastfeeding rates are higher for this population, but this is not true. Hospitals have adapted policies that encourage breastfeeding to mothers of premature infants, but exclusive breastfeeding is still difficult. These mothers have just undergone serious physiological and physical challenges that they were not expecting. This level of emotion can negatively impact the initiation of breastfeeding following delivery. Near the end of pregnancy, mammary growth completes, mammary epithelium is prepared to respond to the infant, and colostrum is produced, preparing for a full milk supply. If a pregnancy is shortened, these things might not have occurred. Milk production can be decreased due to stress, fatigue, and anxiety that many mothers feel in this situation.

                With these factors, most NICU mothers of preterm infants were not able to provide all of the milk necessary to feed their baby an exclusively human milk diet. Formula was used at first, but efforts were in place to find another way to provide human milk.

                Milk banks began to appear at big medical centers. These milk banks screened potential donors for eligibility regarding their health and medication use. They completed a blood test, physical exam, and medical forms. While mother’s own milk still remains first choice for any infant, donor human milk offers a viable alternative if the mother is unable to provide adequate nutrition for her baby. (Landers)

                We know that milk from mothers of premature infants can be different than the milk that mothers of term babies produce, so donor human milk was tested against babies who received formula or exclusive mother’s milk. No significant different in clinical outcomes regarding growth, anti-infectious processes, feeding tolerance, neurodevelopment, or necrotizing enterocolitis were noted between the use of mother’s own milk and pasteurized donor milk, but there was still an advantage over formula. (Giuliani) The American Academy of Pediatrics recommends using donor human milk for preterm infants if mother’s own milk is insufficient despite lactation consultation. (AAP) Donor human milk has largely replaced formula for nutrition supplementation following mother’s own milk.

                In order for a potential donor to pass eligibility, she must not be taking certain medications. This is because babies in this population have immature systems because they did not have the full opportunity to finish growing inside the mother’s womb.  Drug clearance and metabolism rates might be different, which could cause a problem for an preterm infant exposed to this drug even if a term infant was not affected.  Medication use is not seen as an obstacle to breastfeeding most babies, but the different in anatomy and development might pose a problem.  Current milk bank guidelines in the United States are that the only acceptable medications are as follows: prenatal vitamins, human insulin, thyroid replacement hormones, nasal sprays, asthma inhalers, topical treatments, eye drops, and progestin-only birth control products. This limits the amount of eligible potential donors. (HMBANA)

In the last year, Human Milk Bank Association of North America has been studying this topic. They put together a team of medical professionals, including pharmacists and pharmacologists, to determine whether certain medications are proven scientifically safe for donor mothers to take while donating their milk. Although the guidelines have not been released yet, it is rumored that they will be much more inclusive, to allow for other common medications to be taken by the mother. However, each individual milk bank has the option of accepting items that are deemed “acceptable” by these guidelines. It will be interesting to see the new guidelines and to see how the milk banks react to these.

Look for a future blog post on this subject.

Alexis Ireland, PharmD Candidate 2014

References

“Breastfeeding and the Use of Human Milk.” Pediatrics 129 (2012): 826-42.

“Donate Milk.” HMBANA.

Landers, Susan MD and Hartmann, Ben PhD. “Donor Human Milk Banking and the Emergence of Milk Sharing.” Pediatr Clin N Am 60 (2013): 247-60.