Risks of Informal Breastmilk Sharing versus Formula Feeding

Anyone who has even thought about having a child recently has certainly had the "Breast is Best" message hammered into their brain. They have probably also heard countless tales of women who found breastfeeding difficult or impossible and have probably heard them say that infant formula is an acceptable alternative. While there is nothing wrong with those statements, there is a whole lot missing from the middle. What gets lost in the breast vs. formula debate is the option to use donor milk.

According to the World Health Organization's Global Strategy for Infant and Young Child Feeding (p.10):

For those few health situations where infants cannot, or should not, be breastfed, the choice of the best alternative – expressed breast milk from an infant’s own mother, breast milk from a healthy wet-nurse or a human-milk bank, or a breast-milk substitute fed with a cup, which is a safer method than a feeding bottle and teat – depends on individual circumstances. ...

...Infants who are not breastfed, for whatever reason, should receive special attention from the health and social welfare system since they constitute a risk group.

The problem, for any baby that is not able to be exclusively breastfed by its own mother, is that there are risks to any alternate feeding method. In the absence of easily accessible and affordable breast milk from human milk banks, the determination of the best choice for those "individual circumstances" requires an assessment of the risks of various feeding methods that will never provide a clear and perfect answer.

Lacking access to pasteurized human milk

The Canadian Pediatric Association has called for the creation of more human milk banks in Canada and the Montreal Gazette has reported that Hema-Quebec (the blood collection agency) is looking into the possibility of establishing a human milk bank in Quebec. The United States has more human milk banks than Canada, but even there obtaining breast milk from a human milk bank can be difficult and expensive.

Until our governments and health care organizations make human milk banks a priority (like they do with blood), families whose babies need breastmilk (because they cannot tolerate formula) or whose babies would benefit from breastmilk (over formula) are left with no choice but to seek out informal milk sharing arrangements. In response to the growing demand for human milk, a number of informal milk sharing arrangements (e.g. Milkshare, HM4HB - Human Milk for Human Babies) have been established. They have gained a significant amount of profile recently through articles in the Montreal Gazette and Time magazine, among others. Health Canada has raised concerns about these arrangements and the Canadian Pediatric Association has said that it does not support the sharing of unprocessed milk.

However, at the same time, the government is making little progress in ensuring that women are able to feed their babies breastmilk. The government:

• Does not appear to be making any moves towards establishing a strategy for human milk banks in Canada.


• Has signed but does not enforce the WHO Code of the Marketing of Breast-Milk Substitutes.


• Has admitted that it its attempts to stop infant formula manufacturers from using unproven or misleading claims have been ineffective.

In short, the formula companies are not prevented from using unethical marketing practices, we need human milk banks but don't have them, and the government is ready to criticize parents rather than fixing the problem. So, as people lobby the government to fix this problem, mothers who are not able to exclusively breastfeed their babies are left with a difficult choice: informal milk sharing or infant formula. What are the benefits and risks of both?

Infant Formula

The benefits of infant formula are:

• It is a regulated manufactured substance that must comply with certain standards.


• It is easily accessible in a wide variety of convenient retail locations (albeit at a cost that may not be affordable to many).

The risks of infant formula include:

• Babies are more susceptible to bacteria and disease (see "Just One Bottle Won't Hurt" -- Or Will It?).

• Higher risk of wide variety of health problems (see Scientific Benefits of Breastfeedingfor more details), such as:
  
  
  
  • Middle ear infections
  
  
  • Eczema
  
  
  • Gastrointestinal infections
  
  
  • Lower respiratory tract diseases
  
  
  • Asthma
  
  
  • Type 1 diabetes
  
  
  • Type 2 diabetes
  
  
  • Childhood leukemia
  
  
  • Sudden infant death syndrome
  
  
  
  

• Possible contamination of infant formula during the manufacturing process (despite regulations that are in place), e.g.
  
  
  
  • Substances sneaking into formula that should not be there, such as melamine or beetles.
  
  
  • E.zakazakii infections, which can result in neonatal meningitis and has caused the death of infants, is considered to be significantly under-reported in all countries. E.zakazakii outbreaks linked to infant formula has been reported as causing deaths in infants in developed countries as recently as 2004 in France (see WHO's Guidelines in the Safe Preparation, Storage and Handling of Powdered Infant Formula - p.3).
  
  
  • Salmonella outbreaks associated with infant formula have been recorded in Canada, France, Korea, Spain, the UK and the United States since 1995 (see WHO's Guidelines in the Safe Preparation, Storage and Handling of Powdered Infant Formula - p.3).
  
  
  
  
  
  
  • Tampering with infant formula, such as the recent tampering with Nestle Good Start formula cans in Canada.
  
  
  • Use of toxic chemicals such as BPA in the packaging for infant formula.
  
  
  
  

• In susceptible families, breastfed babies who are supplemented with formula can be sensitized to cow's milk protein, resulting in allergic reactions (see "Just One Bottle Won't Hurt" -- Or Will It?).

• Risks in the water that is used to prepare infant formula, including:
  
  
  
  • Possible bacteria in the water (this risk can be minimized by boiling water).
  
  
  • Flouride in municipal water systems, which can cause dental flourosis, may damage the developing brain, can act as an "endocrine disrupter" thereby disrupting thyroid function, and may be linked to bone cancer (see Flouride Warning for Infants).
  
  
  
  

• Contamination or bacteria growth due to improper preparation, storage and handling of infant formula (including not washing hands, not sterilizing bottles, etc).

Some of the risks of using formula can occur even with just one bottle (e.g. gut closure which makes the baby more susceptible to bacteria and disease) and others occur only when a baby is exclusively formula fed. Or, put another way, every bit of breastmilk helps, but exclusive breastfeeding is required to gain the full range of benefits that come with breastfeeding. From that perspective, when a mom is unable to produce enough milk to exclusively breastfeed, it is understandable that the World Health Organization recommends using donor milk before considering formula.

For some babies, the risks of formula are more acute than others. Some infants are able to grow and develop on infant formula. However, some babies with failure to thrive, formula intolerance, allergies and other medical conditions may not be able to use formula at all. The fact that there is only one human milk bank in Canada is an even bigger injustice for those babies than for for the average baby that cannot access donor breastmilk.

Informal Milk Sharing

The benefits of informal milk sharing are:

• Babies have access to human milk, which is designed by nature to meet their nutritional needs.


• Babies, especially those at risk, do not have to be exposed to the many risks of infant formula. This is especially beneficial in instances where the donor milk would be used on a temporary basis (e.g. as the mom builds her supply), thereby allowing her to avoid the risks that come from the introduction of a small amount of formula.


• Families save money by not having to purchase extremely expensive and difficult to obtain pasteurized milk or infant formula.

The risks of informal milk sharing include:

• Possible transmission of HIV via breastmilk. However:
  
  
  
  • According to the CDC:
    
    
    
    • The risk of HIV transmission from expressed breast milk consumed by another child is believed to be low because:
      
      
      
      • In the United States, women who are HIV positive and aware of that fact are advised NOT to breastfeed their infants
      
      
      • Chemicals present in breast milk act, together with time and cold temperatures, to destroy the HIV present in expressed breast milk
      
      
      • Transmission of HIV from single breast milk exposure has never been documented
      
      
      
      
    
    
    
    
  
  
  • According to research from the University of California:
    
    
    
    • Babies that do not receive any formula have a much lower chance of contracting HIV from contaminated breastmilk than those who have received some formula.
    
    
    • Flash heating can be used to kill the HIV in breastmilk.
    
    
    
    
  
  
  
  

• Possible transmission of other sexually transmitted diseases:
  
  
  
  • It is recommended that women with syphilis and herpes do not nurse (or feed milk pumped from) a breast that has sores on the nipple or areola.
  
  
  
  

• Prescription or over-the-counter drugs, alcohol or tobacco use by the donor:
  
  
  
  • Most drugs are minimally excreted into breastmilk and many drugs are perfectly safe to take while breastfeeding.
    
    
    
    • According to the Newman Breastfeeding Clinic and Institute "there are plenty of risks in not breastfeeding, so the question essentially boils down to: Does the addition of a small amount of medication to the mother’s milk make breastfeeding more hazardous than formula feeding? The answer is almost never. Breastfeeding with a little drug in the milk is almost always safer. In other words, being careful means continuing breastfeeding, not stopping." This is echoed by Health Canada. There are certainly some drugs that are unsafe, but generally women who are taking those drugs would not be breastfeeding and therefore not be in a place to be donating milk.
    
    
    
    
  
  
  • Alcohol does pass into the breastmilk, but only in very small amounts. A woman would have to be very drunk while breastfeeding/pumping in order for it to create a risk to the infant. Small amounts of alcohol while breastfeeding is fine.
  
  
  • Mothers who smoke are encouraged to quit during pregnancy and breastfeeding. However, smoking and breastfeeding is still better than smoking and formula feeding.
  
  
  
  

• Possible contamination of milk through improper storage or handling (similar to with formula, albeit with some different guidelines to follow).

A lot of these risks can be significantly mitigated by screening the donor through interviews and blood tests. Human Milk 4 Human Babies has a series of suggestions on things you may wish to discuss with a potential donor in their FAQs (e.g. Recipients can ask donors to take blood tests or other health screenings).

The recipient parents will have to decide what they are willing to accept and not willing to accept from a donor. Some may be willing to accept a donor who smokes, has a glass of wine with dinner, and takes an Advil every once in a while. Others may decide that they are not willing to accept that. Some parents may decide they are only willing to accept donors they know personally because being able to trust the other person is important to them, whereas others may be willing to accept milk from a stranger if they have undergone certain screenings.

Which is riskier? Informal human milk sharing or formula?

It is important to remember that both informal milk sharing and infant formula have risks. In both cases, some of the risks can be mitigated, but they cannot be entirely eliminated. The difference between the two is that:

• Many of the risks of human milk can be significantly decreased or eliminated through diligence on behalf of the donor and recipient.


• Many of the risks of infant formula are ever-present -- i.e. no amount of care or diligence by the formula companies or the parents will erase the health problems that can result from feeding formula.

Which risks are you more willing to accept -- those that come with infant formula or those that come with donor breastmilk? How much work are you willing to do in order to provide your baby with breastmilk? Those are questions that only you can answer. For some, those answers will come easily and for others the decision making process will be agonizingly difficult.

It shouldn't have to be this hard though. Something needs to be done about the availability of pasteurized donor milk in Canada, especially for at-risk babies and for short-term needs (e.g. a mom who is suffering from a short-term supply issue).

Image credit: Daquella manera on flickr

Comments

[Pamela]

I've donated informally and will continue to do so whenever I can and whenever someone asks. I strongly believed that it was a better alternative. In both cases, moms of babies roughly the same age as my son (6-8 months) unexpectedly got pregnant and their milk supplies dropped.

Both babies were small for their age and we were going into flu season. I gladly shared my milk with them at a time when their mothers were going through a tough time in milk production, and would have had to supplement with formula as they were not big on solids yet. A milk bank was not a viable option because of the age of the babies and because it was cost prohibitive.

[Kim aka BeautifulWreck2]

I donated breastmilk for six months to a friend of mine who had a baby five days before I did. We had enjoyed being pregnant together and our babies were due about six weeks apart. I had my baby early, hers was a few days late. She had trouble producing milk where I had more than an enough to feed two babies. I made the offer to donate after her pediatrician suggested she do something different since her baby was not growing or gaining weight after a month and lots of intervention to help her produce more milk.
Our arrangement was a good one and it was also safe. I was more than willing to share my medical info with her and due to having a surgical birth vs her homebirth, I had gone under every test imaginable for STDs and AIDS. She knew our lifestyle and was also aware of an anti-depressant that I took for PPD. She discussed it with her pediatrician and he gave her the go ahead.
Luckily we lived in close proximity of each other and milk storage was easy.
I have recommended this kind of arrangement to other mothers but some look at me horrified. I insist that it is safe, even safer than formula feeding but they can't seem to get over it is a bodily fluid. I guess milk from a cow is not seen that way. @@

(BTW I have supplemented with formula and believe it has it's place. I'm not anti-formula. I just knew that my friend had her heart set on breastfeeding and did not want to use formula and thus made the offer)

[Away from your crazy mom]

I wish this option had been mentioned to me after my son was born and we were both hospitalized and he was given formula while I was waiting for my milk to come and for his suction reflex to quick in. I understood we had no choice, but I always felt a bit cheated.

[mamarolf]

As usual, thought provoking and thorough. Personally, I have both donated milk and fed my baby donated milk. I think the most important thing is that parents have access to the information they need to make an informed decision about what is right for their family. You have helped to further that with this post; thank you.

[Aida N]

Kim - that is beautiful. It's lovely that you offered and equally lovely that your friend accepted. It must be satisfying to know that you nourished and helped grow 2 wonderful children.

Before I had my 1st son, 3.5 years ago, I would have considered milk sharing/donating a very weird thing. I probably would have even frowned on it. But that would have come from an ignorant place. I did not know then how important breastfeeding truly is. Now, I am older and wiser. I would donate in a heartbeat if I could and if ever I could not produce milk for my baby I would definitely seek out donor milk (or a wet nurse).

[Fearless Formula Feeder]

While I agree that donor milk should be a more viable option for women, I think it's a bit of a stretch to go with Jack Newman's philosophy on the relative risk analysis of donor milk vs formula. First, he is more than a little bias - I'd go so far to call the man a zealot (and I'm not saying zealotry doesn't have its place; I realize he has done quite a bit for the lactivist cause, and I admire his zeal, to some degree, but we need to recognize bias when it is present). Second, there are a REAL shortage of good, long term studies done on medications and breastmilk. I've done the research and the results are far from comforting for a fair number of medications, including many psychiatric meds which are widely used these days. Thomas Hale is the best resource we've got, but even he has been limited by a lack of research. Most of the studies he's using are based on tiny samples and in the short term.

What about the option of a modified wet nursing situation? A dear friend, for example, had a plentiful supply, and basically pseudo-wet nursed her nephew (via pumped milk), whose mom had limited supply due to a breast augmentation.

Regulated milk banks are the best bet - I would definitely feel safe using donor milk from a bank- but we need more of them, and they need to be less cost-prohibitive.

[Amy]

Thank you for an awesome post! This will help many moms see the decisions they have to make for their babies in a much less confusing light. The conclusion that the risks of informal breastfeeding are easier to mitigate because you can't control what formula companies are doing is a great point that I think will help many parents see the positive light of milk sharing.

I think that a lot of women skip over the idea of milk sharing and informal breastfeeding because if a fear of the unknown or a lack of confidence in the methods of using donor milk or a "proxy breast" so to speak. This gives clear information that will help with these concerns for sure.

Another benefit of informal breastfeeding that you might want to consider including is that baby benefits emotionally and developmentally from the act if feeding at the breast instead of being bottle bed donor milk or formula. It doesn't matter whose breast it is - or if baby switches from mommy to proxy and back again - the benefits of the act of breastfeeding are still present, and those benefits are important from birth through childhood. Just a thought!

[phdinparenting]

Fearless Formula Feeder:

I didn't know that I was using Jack Newman's philosophy. I did my own research for this article and did reference Jack Newman in one place (on medications), but wasn't aware that he had written specifically on this issue (or perhaps I would have just linked to his post instead of bothering to write it myself).

With regards to medication, I personally would be very cautious. But I was also very cautious in terms of what I was taking myself while nursing. I would imagine that most nursing mothers are and that most potential donors are probably not taking anything that isn't perfectly safe.

I wouldn't have any problems with a modified wet nursing situation. I think that is what most of these informal milk sharing situations amount to. The donor and recipient communicate with each other, answer any questions/get tests done, and then proceed (or don't proceed) as they see fit.

[Alison]

Brilliant post on the relative risks of donor milk versus infant formula. There is more than enough human milk out there for all human babies, it is just a question of distribution and not supply.

[Amber]

My daughter was born at 34 weeks, and was given a bottle of formula in the NICU before I was able to try breastfeeding, and without consulting me. I will say that I would have felt quite a lot more comfortable if that had been expressed breast milk instead. Interestingly, had she been born at another hospital here in the Vancouver area, it likely would have been milk from the milk bank.

Having said that, I think that we still need to be cautious of donor milk in the same way that we're cautious of formula. What I mean is that when a baby receives donor milk, it is typically from a bottle, and it is a time when the baby is not taking milk from the mother. In the case of my daughter, even if she had been given donor milk instead of formula, it would still have been the case that her first feed was from an artificial nipple instead of at the breast.

I believe that we need to do more to support milk banks. I believe that it is up to each parent to decide if they are comfortable with informal milk-sharing. But I also believe that we need to do much more to support mothers in breastfeeding successfully themselves. And if donor milk is used, it needs to be used in such a way that a mother's milk supply is protected, particularly if it's intended as a short-term "get over the hump" sort of measure.

[Jeannie]

I noticed your comment that "Smoking and breastfeeding is still better than smoking and not breastfeeding." You gave no facts to back this particular claim, and you certainly didn't prove that carcinogens from tobacco by-products are not passed on thru breast milk. So I think you should use your high standards on all your facts, not just those convenient to you. Also, claiming that formula leads to Type 1 and Type 2 diabetes is pretty darn arrogant. DM 1 is an intrinisic condition in which a child secretes no insulin, not something formula or breast milk can induce. Finally, you say that ear infections are something formula nurslings are at risk of, but as a breast feeding mama, I know that ALL babies are at risk of ear infections, as their heads are parallet to the breast or bottle and milk can pool behind the ear. So, your arguments were kind of weak, to me, especially since you only list 2 PRO's of formula...and really downplay the role of alcohol in milk as a risk factor. Don't write that a mom has to be "really drunk" for it to affect baby. That gives allot of women a HUGE margin of error, and once your "pretty drunk" it can be hard to tell once you are "really drunk".

[Kim aka BeautifulWreck2]

Would like to make two points based on additional comments:
I would hope that the use of anti-depressants wouldn't discourage mothers from using donor breastmilk in an informal sharing arrangement, just as I hope it would not discourage women from breastfeeding should they need them to treat post partum depression. Diet and alcohol consumption would be a greater concern to me than the very small amounts that pass through breastmilk.

And I couldn't agree more that this should be used to "get over the hump" but I know from personal experience that the friend I helped had a low supply with her previous children and then with the current child. Her milk supply could not and wasn't supporting her baby. Also in the case of mother's who adopt infants who would like to do this, they may also never get a full supply to meet the babies needs. (I also breastfed and received donor milk for the child we adopted)

[Kim aka BeautifulWreck2]

I had a premature baby as well. She had low blood sugar and she was unable to nurse due to being on oxygen. I was unable to give breastmilk because I had complications with surgery. However they did discuss with us giving her an IV vs giving her formula in a syringe because they knew breastfeeding was important to me. It turns out that IV of fluids would have been more detrimental than a syringe of formula to her breastfeeding and so that is what we opted for. Formula or donated milk does not have to be given by bottle - they have special feeders or it can be given with a syringe. For the first week or so my youngest did get formula when she experienced low blood sugar but she always got it in a syringe. (never had any luck with a SNS feeder)

[Smrt Mama]

I've donated quite a bit of breastmilk over the course of my last two babies, probably in the neighborhood of a couple thousand ounces. All of it was through informal donation and in all but two cases (one through MilkShare and the other a "friend of a friend" scenario), I donated to people I knew personally.

Responsible donation eliminates the vast majority of risk involved in informal (or as I prefer to call it, direct) donation. Before considering donation, I got screened for a wide range of STDs and other blood-borne illnesses (including CMV). I live a pretty darn risk-free lifestyle, don't drink heavily/regularly, take no regular prescription meds, and made sure my recipients were aware of my occasional use of OTC meds (ibuprofen and Benadryl, primarily) and vitamin supplements (because a B-50 complex can sometimes turn expressed milk rather green!). My two most regular recipients used the donor milk at the breast with a SNS, so their own milk supply continued to be stimulated while the baby nursed/received donor milk.

I can't imagine substituting formula if donor milk were available. It just seems so much more normal to me to feed human milk from another healthy mother. Of course, my mother was also a direct milk donor when she was nursing my younger brother, so this was presented as a perfectly normal thing to do for another woman/baby in need. I think that has the most to do with my mindset on it.

[Smrt Mama]

Agree completely that there are definitely moms out there who need more than "getting over the hump" and that's one reason why direct donation is SO important. Affording a small amount of milk bank milk -- if you can get a prescription for it, of course -- for short-term use might be financially possible for many families, but the cost of banked milk is cost prohibitive for families who have a long-term need. One of my former regular recipients has insufficient glandular tissue and really relied on donor milk to help ensure her baby was getting enough in a day. She did everything in her power (including reglan, domperidone, herbal supplements, pumping, etc.) to increase her supply, gave all the supplements at the breast, and still was not producing enough to meet her baby's needs. Because she was putting so much money into maintaining and building her own milk supply, there just wasn't anything left for a milk bank.

[Smrt Mama]

I think that "modified wet nursing" you're describing really is how most direct donation is happening -- it's friend to friend, or friend-of-friend to friend. While some babies are in such dire need of breastmilk that parents are forced to look beyond their immediate circle, I think that there's a lot of less-documented, less-discussed milk sharking (and cross-nursing) going on within families, friends, and communities.

[Smrt Mama]

And by "milk sharking," I of course meant, "milk sharing."

Though milk sharking is WAY funnier. Ouch!

[Dr Sarah]

Thanks for a really interesting and well-thought-out post. I'm hoping to have the time to read it and comment in more detail at a later stage, but there was one point I absolutely *had* to correct:

**The overall evidence does NOT support the claim espoused in the 'Just One Bottle' article that giving even a single bottle of formula to a breastfed baby is likely to be risky.**

In fact, most of the available evidence that we have on the subject of the effects of an occasional bottle in a breastfed baby is reassuring as to the *lack* of harm found. I wrote about this at http://goodenoughmummy.typepad.com/good_enough_mum/2010/07/the-case-of-the-lactivist-propaganda-a-reply-to-ann-calandro.html. I'm very concerned about the way the claims of the supposed harms done by a one-off bottle are overhyped in the face of the evidence, as I think it's causing a lot of entirely unnecessary anxiety for new mothers and may even be backfiring badly by leaving mothers who can't or don't want to breastfeed exclusively with the impression that it may not be worth breastfeeding at all. And, of course, in this context, I'm concerned that exaggerating the risks of occasional formula as compared to donated milk may be giving mothers the wrong information on which to make their decision. I would therefore ask you to consider amending or taking down those references in your article.

[Stephanie]

I donated milk to my younger sister when she had trouble establishing a supply with her youngest. Helped her get through a rough spot in her breastfeeding. It was the indirect method with pumped milk, but it still shocked her husband at first.

[Heather]

Interesting. I have twins via a surrogate mother, and although I've induced lactation for them, I still need to supplement quite a bit. I think the question "How much work are you willing to do in order to provide your baby with breastmilk? " is misleading. You make it sound as though if one works hard enough, there is enough donated breastmilk for everyone. I am on Milkshare looking for donors every day, and I can tell you that the demand is much much higher than the supply. I have worked every day for the last 8 months to get my babies breastmilk, and they still drink lots and lots of formula because there just aren't enough donors.

Also, while one would assume potential donors are not taking hazardous medications, this is not always true. I had to turn down one Milkshare donor because she was taking a medication that Dr. Hale says does pass into the milk in fairly large amounts, and is risky. Is it riskier than formula? I can't be sure, but I also don't feel comfortable taking the risk of the medication on their behalf.

[Our Sentiments]

Great post PhD In Parenting! I was waiting for you to shed some light on this topic.

I personally would had rathered K2 be mistakenly given a bottle of someone else's breastmilk than the formula they gave to her behind my back in the NICU. I am glad this is happening and I am glad more parents have more options. I do hope that there will be more milk banks, however who could pay the for that?

[Natalia – Baby Guroo]

I was fed human milk from a hospital milk bank as a supplement. It was in Russia 30 years ago. My mother still emphasizes that it wasn't formula, but real breastmilk. There are of course a lot of differences between Canada now and Russia then but still I am a little surprised how easily the milk was available to the women at that hospital: every mother with a low supply was referred to the milk bank.

[phdinparenting]

Dr Sarah:

I think we are referring to two different articles, albeit on the same subject. My link goes to Marsha Walker (RN, IBCLC)'s article on the topic, not Ann Calandro's. I have sent Marsha an e-mail and asked her to reply here to your comments. I hope she has the time to do so.

[phdinparenting]

Heather:

I didn't mean to suggest that if you work hard enough, there is enough donated breastmilk for everyone. It was an honest question that I think people need to ask themselves, but still not a guarantee that if you do all the work that there will be sufficient supply. At least not now. There may be in the future as these types of milk sharing arrangements become more common. I did give my son some formula when I was exclusively pumping for him and my milk supply dipped significantly due to mastitis. If I had known about the option of milk sharing at the time, I don't know if I would have used it or could have used it. I had an immediate and temporary need, with no real advance warning, so I wouldn't have had time to go through extensive screening with a potential donor in time to feed my son. My point was that it is a lot of work. You can't just run to the store and buy breastmilk like you can with formula. There is a lot of effort required and it may be too much effort for some people and some circumstances.

[Aida N]

Kim, great point about not necessarily using a bottle. There are other ways to feed a baby... when my 1st was born and he dropped almost 10% of his weight I wasn't given any other option than formula. I had no clue how to manually express so the thought never occurred to me. But, I had read enough to be aware of the issues that may arise due to using a bottle & artificial nipple so I fed him by syringe. There is also finger and cup feeding as a possibility (depending on the age of the baby). SNS are great if they work.

Of course, if this was going to be an extended option I do think that eventually using a bottle would make sense if a SNS doesn't work.

[Sandra]

Hi,
While I cannot speak to your personal experience finding donors, I would like to point out that breast milk is not scarce nor is it a limited commodity. The issue is with getting people in touch with one another. I am sure that within a few kms from your home there are some women with freezers full of milk that will be thrown out because they do not know about the possibility of giving it to other babies in need.
Your example about the donor taking medication is a great example of how informal milk sharing empowers women to make their own decisions and set the limits of what they are comfortable with.
I hope you have better luck in the future getting milk for your babies. You should check out your local chapter of Eats on Feets.

[Alina]

Reading your post makes me think of the risks of putting any food other than breastmilk into the mouth of an infant..... I have known mothers who would NEVER give a 8 month old formula feed that same 8 month old: french fries from McDonald's, Doritos, sugar-laden juice and various other processed 'junk' foods.

[phdinparenting]

Alina:

Yes, there are risks to all sorts of things. However, the risks are more acute before the age of around 6 months. The gut closes naturally sometime between 4 and 6 months and the risks are decreased then. Also the risks of something like infant formula versus something like McDonald's is different. If something has been deep fried, then bacteria isn't generally the concern. But there are certainly other concerns.

[Marsha Walker, RN, IBCLC]

This is a wonderful article and part of a very important discussion regarding the properties of human milk and its importance relative to potential problems with the use of infant formula. Dr. Sarah has indeed confused two similar articles and appears to be commenting on one written by someone other than myself. I believe that my document presents a cogent approach with evidence back-up relative to the affect of infant formula on the gut of a breastfed infant. I do not think it dissuades mothers from breastfeeding. On the contrary I believe it gives them information that is absent from discussions with health care providers and certainly is not found in infant formula marketing hype. It was written to help health care providers understand the side effects of the cavalier supplementation of breastfed babies.

Breastfeeding enhances the maturation and protection of an infant's immature organs, because breast milk contains hormones (prostaglandins, cytokines, growth factors), antibodies, anti-microbial components (lactoferrin, fatty acids, oligosaccharides) and maternal lymphocytes. Mother’s milk also contains prebiotic oligosaccharides that prevent the establishment of inflammatory adult bacteria and stimulate probiotic, anti-inflammatory gut flora. Formula attempts to approximate mother's milk, but the deficiencies delay gut maturation, promote inflammation and increase the risk of numerous infectious and autoimmune diseases.

Mothers have the right to know this information. The risks are not exaggerated.

[FoxyKate]

You focus on Canada & the US here - do you know of anyplace that has a good, solid milk banking support system in place?

[Dr Sarah]

Annie, one point that just occurred to me is that in the case of both gastroenteritis and otitis media, we don't know how much of the difference in rates between breastfed and formula-fed infants comes from the breastmilk itself, and how much comes from the mode of feeding. Once milk is stored and put into a bottle, there's increased opportunity for bacterial contamination compared to feeding directly from source. The sucking action required from bottles is different, and there are theories that this may account for at least part of the increased risk of otitis media seen in formula fed babies. And, of course, donated milk has usually been frozen at some stage, and that may well destroy some of the factors in it - I don't know how much data is available on this topic, but I do know that when I was storing milk I was advised that defrosted breastmilk had a lifespan in the fridge similar to formula, in contrast to fresh breastmilk that could live in the fridge for several days, because some of the immune factors in breastmilk that helped fight off the bacterial contamination that led to souring were destroyed by the freezing process.

What all of this means is that the benefits of breast*feeding* as compared to formula are not necessarily the same as the benefits of feeding defrosted breast milk from a bottle. Mothers basing their risk-benefit analysis on studies comparing breastfeeding with formula feeding may, for all we know, be using figures that simply don't apply to using donated milk.

[Dr Sarah]

Oh, I'm aware of the fact that these are two different articles. But, as far as I can see, Marsha Walker is making the same claims that Calandro made and that I rebutted: i.e. the claims that 'just one bottle' can lead to an increased risk of gastrointestinal infection and allergies (and of diabetes, which I didn't rebut so much as try to put into perspective). I'm not clear on what claims you feel Walker made that weren't covered in my post.

If I get a chance, I'll write a post specifically discussing Marsha Walker's article. If you can let me know what points from Walker's article you feel weren't covered in my rebuttal of Calandro's article, I'll try to focus on those.

And, Marsha, thanks for replying; but I wasn't questioning the claim that breastfeeding is better than formula feeding, with which I heartily agree. I was questioning the claim that giving a *single bottle* of formula to a breastfed baby has been proved to put the baby at significant risk of harm.

[ThoughtfulBirth]

I appreciate this straightforward comparison of the risks and benefits of formula and donor milk, but I do want to take issue with one major assumption: that volunteer/private donor arrangements are somehow inferior to government-run programs. Your mention of blood banks, for example, completely ignores the fact that the Red Cross (a private nonprofit) and community blood centers are the primary collectors and providers of donor blood in many, if not most, areas of the U.S. (I can't speak for Canada here.)

If our current milk banks are too restrictive and expensive to meet the needs of the community, and other organizations (such as Eats on Feets) and individuals are taking the initiative to fill those gaps at no cost to the taxpayer, in a way that lets each mother choose her own restrictions and priorities (for example, many recipient mothers do not _want_ pasteurization because it destroys the antibodies, enzymes, and probiotics that comprise many of the benefits of breastmilk), then why in the world would we want a bureaucracy to step in and start enforcing arbitrary and one-size-fits-none levels of organization, standardization, and price?

[phdinparenting]

ThoughtfulBirth:

I do not think the program has to be government-run, but I do think our government has the responsibility to develop a strategy that would increase access to donor milk for Canadians. In Canada the Red Cross is no longer allowed to collect blood due to a tainted blood scandal. It is now collected by Canadian Blood Services in most of Canada and by HEMA Quebec in the province of Quebec. They are both non-profit charitable organizations, but are heavily regulated by the government.

[phdinparenting]

FoxyKate:

I am not sure. It isn't something I've researched a lot. Perhaps one of my other readers knows or, if not, maybe I'll look at it for another post.

[Mama in the City]

Amber,
You should be happy to hear that as more Pediatricians are becoming educated on breastfeeding, NICU and prematurity, I am finding they are more reluctant to give formula or breast milk through a nipple bottle system. Instead, babies that are too compromised to nurse at the breast, are having a feeding tube placed from nose to tummy and their food is put through that. This is to protect the chance of nipple confusion and to encourage ease of learning to latch on a breast when the babe is stronger. So far, in only an observational role, I am finding that breastfeeding is more successful. Yeah!

[Heather]

Oh, how I wish I could just run to the store and buy it! :) I think I was sensitive to the question because with my first daughter (who was EBF), *I* simply assumed that if one did work hard enough, no baby would have to drink the dreaded formula. It has been humbling to discover that it simply isn't the case. But like you say, maybe as time goes on there will be more opportunities and greater resources available for mothers to share their milk.

[Heather]

I totally understand that - in fact, I had oversupply with the daughter I gave birth to, and I was one of those women who threw away her freezer stock. I am sure there was a mom nearby who could have used it, but at the time, I just didn't know how to go about donating.

Thanks for the good wishes - I intend to keep on trying to find donors until the babies reach a year, and then I think I'll give up the fight. :) I will definitely check out Eats on Feets. Yesterday was the first I had ever heard of it, and I am so glad to know there is more milk sharing going on out there!

[Ingrid]

This is in your section of risks of formula feeding. I think it is a typo: In susceptible families, breastfed babies can be sensitized to cow’s milk protein, resulting in allergic reactions (see “Just One Bottle Won’t Hurt” — Or Will It?).

[Sarah @ BecomingSarah.com]

I had a prolactin imbalance, so I produced a shit-ton of milk in the first few months. You hear about women producing too much, but there were days when I pumped an extra gallon. My biggest trouble early on was staying hydrated.

As a result, I have donated milk to a donor bank, informally to friends, and I've informally wet-nursed over the past 16 months. I always kept up-to-date with my blood tests to show that I do not have any diseases of concern and I always informed the recipients - be they bank or parents - whenever I took antibiotics or other medications or if I drank. I also made sure that in informal milk sharing, I always labeled expressed milk with the date and time and delivered it with a list of foods I'd been eating, so that parents could determine for themselves if there seemed to be food sensitivities.

I think that milk sharing can be done safely and that the benefits of raw milk especially are worth the risk if you can find a donor you trust. But more than anything, I think that these organizations have developed to meet a need. If the government - American or Canadian - were meeting the need, we wouldn't have a problem. But they aren't. Donor milk is hard to come by and it's expensive, so instead mothers who need or want breast-milk for their babies are forced to find creative alternatives. If the government doesn't like it, then they should start finding a way to make donor milk and wet-nursing widely and safely available at low prices and they should start educating the public about the viability of those options. Until they start making an effort to meet the needs these parents feel are unmet, they don't really have a leg to stand on.

[Montreal Milk Share]

Great post! I would have loved it if you would have included my service with your other milk sharing links.
Thanks!
Mika of Montreal Milk Share

[kelly @kellynaturally]

When my first child was born with ABO incompatibility (which causes severe jaundice), and my milk was not in, we gave her formula, as recommended by the pediatrician & LC (via an SNS), mixed with whatever precious tiny amounts of colostrum I was able to pump. I rememer having read that article about gut closure before she was born - and that ANY amount of formula would damage her gut flora.

It terrified me but I wasn't even offered the choice of donor milk, and to be honest - it didn't cross my mind after a very long labor, followed by a cesarean section, and incubated daughter. My LC reassured me that the colostrum my daughter had gotten for three days previous to any formula would protect her gut - I can only hope there was not serious damage done by the formula supplementation.

I do wish the option of donor milk was offered - I would have taken it in a heartbeat.

[phdinparenting]

Ingrid:

I don't think it is a typo. What makes you think that?

[McMama]

As a gestational surrogate, my Intended Parents and I have agreed that I will nurse their baby in the hospital and pump for them as long as possible afterward. It is technically an "informal" situation, since we won't be going through a bank, but they know that I've been screened and tested (before carrying their baby) and if they trust me to bake the baby, they trust me to feed him as well.

[phdinparenting]

McMama:

That is great! If the Intended Parents includes a woman (i.e. not same sex male couple), is she also planning to induce lactation? If she was, then your milk could help them feed the baby in the initial stages, but could eventually be replaced by her own milk.

[Kristine]

I think this is just the kind of dialogue we need to be having. Instead of re-hashing the same old FF vs. BF debate, we need to be talking about infrastructure (like milk banks), support available to parents, and education that medical professionals receive.

[phdinparenting]

Dr Sarah:

I agree that we need more research that compares breastfeeding with exclusive pumping and formula feeding to get a better idea of that. The only research or analysis that I am aware of is on the enhanced immune response that results from nursing directly at the breast, which is one of the reasons that I chose to nurse my son at least once or twice per day even when his latch was horrible. I wasn't sure if we would ever be able to nurse full time (eventually we were able to), but I wasn't willing to give up that time at breast due to the benefits that it conferred.

[Melissa]

A fantastic and well-researched post - thank you! I personally would choose milk from a carefully screened direct donor over pasteurized banked human milk any day. I am so glad that the network of willing donors is growing and I hope that more mothers with supply issues or conditions making breastfeeding difficult will discover the option. At the same time, I think support for new breastfeeding mothers, enabling and empowering them to build a strong supply and nurse their own babies should be the number one priority, over both building that network and establishing more milk banks.

[Adrienne]

Some of your information is incomplete:
Moms with syphilis should be treated for the disease. It is treatable in most cases these days.
To say that a mom has to be "very drunk" to have significant amounts of alcohol in her milk is misleading. But I agree that light drinking is compatible with breastfeeding in most cases, especially if the baby is not a neonate. Mothers who are nursing should be encouraged to limit alcohol and not engage in heavy drinking.
E. sakazakii is now re-named and given a new genus: Cronobacter. The reason for the change is that there are other, related organisms. These bacteria cause many serious diseases aside from severe meningitis, especially in premature babies: necrotizing enterocolitis (as bad as it sounds), pneumonia, and sepsis. Babies often die if they contract it. The only real source right now is infant formula, and it is a contaminant, not a native cow's milk bacterial species.
Part of what may inhibit mother-to-child transmission of HIV via breastmilk are bacteria--the Lactobacilli native to human milk.
Breastfeeding is associated with reduced risk of all types of childhood cancers.

Yes, any formula, especially early on, can damage baby's gut, alter GI flora, predispose baby to allergies, and compromise baby's immune response. Most pregnant women know their HIV status, because they are tested during pregnancy. The reason that we're not sharing milk is the tail wagging the dog--liability concerns making us recommend something far more dangerous.

[Crunchy]

The one time my milk REALLY came in was when I didn't need it. My boobs were exploding after delivering my dead son and it was just another punch in my gut.

If I had known about it or been told, I would have gladly pumped and donated my milk to the local milk bank down at BC Women's.

Some good out of horror.

Needless to say, I felt guilty for accepting milk from the milk bank when I had Tara. My milk once again was not coming in and I was exhausted and frustrated and depressed. When my midwife suggested the milk bank I was thrilled and honored that I would be ALLOWED to use another mothers milk.

I used it just for a short while to supplement....and then stopped....I felt that milk was too precious for my healthy and hale daughter and felt that that precious commodity should be going to the preemies and other babies in need.

But ALL hospitals with maternity wards should have a vibrant and OPEN to all milk bank...what a great way to at least START a child who may end up on formula or not.

I am forever grateful for that milk.