In recent years, donor milk has become an increasingly popular infant feeding option. This has happened for a variety of reasons. Hospital staff members frequently ask me how they should handle situations when parents want donor milk for their baby. Often, shrouded somewhere in their question is the assumption that donor milk is not allowable. In many cases, there are “unknowns” that could affect my answer. But my first response is usually along the lines of, “What’s your hospital policy on donor milk?” There are several variations, but most times, the theme boils down to two possible scenarios.
What are the most likely scenarios?
- There is no hospital policy on the use of donor milk. There’s a policy on breastfeeding, and possibly a procedure for how to store the mother’s own milk, but no policy that specifically addresses the use of donated human milk.
- There is a policy on donor milk, and it specifies that the milk must come from a milk bank accredited by the Human Milk Banking Association of North America (HMBANA). Typically, such a policy exists for preterm infants who are being cared for in the NICU.
Both situations leave many questions for the staff to deal with.
Thorny issues arise when a hospital policy on donor milk does not exist
Sometimes, clinical leaders are reluctant to write more policies. But without a policy to guide them, staff face thorny situations, and often, encounter more questions than answers.
- The parents ask for donor human milk. (And, in some cases, their insurance might cover it!) The staff has no idea how to respond. Why not? Has the hospital simply never explored the possibility of obtaining donor milk? Or, do providers prescribe the milk, but there’s no formal hospital policy on donor milk, or no procedure for how to obtain it?
- The physician will not prescribe donor human milk. But, the staff tells parents that they cannot bring in milk from the outside. Without a policy that prohibits such action, is that response justifiable?
- The parents bring in milk that from a “private milk bank,” or from a neighbor, or even from a stranger. The parents aren’t asking staff to locate or procure the milk, they’re just insisting that the baby get what they have brought to the hospital. With no hospital policy on donor milk for guidance, what should hospital staff do if the parents feed it to the baby?
- The parents want human milk for their baby, and donation is their only means by which to get it. If milk from a HMBANA-accredited milk bank is not a possibility — for whatever reason — what other options do the parents have? What is our role in helping them?
Addressing donor milk from three perspectives
It is critical to draft all policies using the basic anatomy of a policy. However, a hospital policy on donor milk should specifically address these issues:
- the mechanism by which milk from a HMBANA-accredited milk bank can be readily available in the hospital
- indications for donor milk, including “traditional” needs (e.g., a preterm baby is in the NICU and the biological parent is requesting donor milk) as well as other needs, for example, any situation where the non-biological parent is requesting milk for the baby
- how the staff will be educated so they can explain to parents the various sources of milk along with related pros and cons and the practical issues associated with each.
Differentiating sources of the milk
Milk from HMBANA-accredited human milk bank: This milk undergoes a rigorous screening and Holder pasteurization. It is available based on need, for use in the hospital setting or at home, for long-term or short-term purposes, with a physician’s prescription.
Gestational surrogate: The optimal source of nutrition in any surrogacy situation is the woman who experienced the pregnancy. If she is able and willing to lactate for the baby, all involved should support her, because her milk would be uniquely suited for the newborn.
Informally-shared milk: Nowadays, parents often connect through groups such as Human Milk 4 Human Babies and Eats on Feets. The World Health Organization (WHO) recognizes “milk from a healthy wet-nurse or from a human-milk bank” as a viable infant feeding option when breastfeeding isn’t possible.
A word of warning here, though. Some parents may be forthcoming about their intentions to use shared milk, but some may not. What to do about the “shared milk” creates another level of complexity. It is impossible to tell whether milk that is brought into the hospital is coming from an outside source or the infant’s mother. Even if it seems that milk is coming from an outside source, staff cannot confirm this. Again, a good hospital policy on donor milk that addresses shared milk can help to guide the staff.
Another situation that may arise is when parents ask the staff to locate milk and set up the exchange. For ethical reasons, professionals should never “broker the deal” and connect patients with donors.
Informing parents of risks from shared milk
Parent often believe that there are no risks associated with milk sharing, but that’s just not the case. Some risks may be minimal or inconsequential; some could be life-threatening. And when there is financial compensation for the milk, the risks may be different. Therefore, staff members need to inform the baby’s doctor of this feeding choice. However, although milk sharing may seem an alarming feeding choice to some, hospital personnel must respect the parents’ role in determining their baby’s nutrition. The baby does not, after all, belong to the hospital, but to the parents.
Using appropriate resources to support your hospital policy on donor milk
Consider several resources when drafting a policy.
- James Akre and others authored a paper entitled “Milk sharing: from private practice to public pursuit,” which may provide some insight.
- The American Academy of Pediatrics in 2017 published its “Donor Human Milk for the High-Risk Infant: Preparation, Safety, and Usage Options in the United States.”
- Also in 2017, the Academy of Breastfeeding Medicine published its “Position Statement on Informal Breast Milk Sharing for the Term Healthy Infant.”
- The Appendix documents (see 4-C and 4-D) compiled by the California Perinatal Quality Care Collaborative. These documents direct the care of very low birth weight (VLBW) infants. They may be more rigorous than your hospital needs in its care of healthy, full-term infants. However, the documents point to issues parents ought to consider, such as donor criteria, informed consent, liability waivers, and milk storage. (Of special interest may be Attachment A1, “Fresh Donor Breastmilk Information Sheet for Recipient Parent.”)
Creating procedures that relate to the hospital policy on donor milk
Remember, a policy is very different from a procedure, and I haven’t begun to address that in this post. But you’ll need to create procedures, as well.
This is a long post, but I feel there must be more to say about hospital policy on donor milk. What did I leave out? Tell me in the comments below!