Liquid gold

The use of donor human milk to feed premature infants when their mother's own milk is unavailable is growing in popularity worldwide. Yet the contemporary practice of human milk banking is relatively new in Australia. A researcher from the UTS Centre for Health Communication is exploring how this practice is widely accepted in the neonatal intensive care units (NICU) of the United States, and how social perceptions about donor milk must change back home.

“I think as a sociologist you can often focus on the problems of the world, but what I like to do in my work is focus on what’s going well and try to make more of it.”

NCIU, The Women’s Hospital, Indiana, USA

This attitude has taken Postdoctoral Research Fellow Katherine Carroll to the United States for six months to investigate the socio-cultural and organisational aspects of what drives the use of donor milk in NICUs. A recipient of an Endeavour Research Fellowship and an Australian Research Council Discovery Grant, Carroll is advocating for a change in attitude to the importance of donor milk, or as she likes to call it, “liquid gold”.

Carroll has been observing the daily work practices of NICU clinicians, focusing her observations on the medical decision-making surrounding infant feeding and the parental consent process for donor milk use. In addition, she’s interviewing human milk bank staff to understand the issues faced in preparing suitable donor milk for NICUs. Carroll says there are more health benefits and cost savings to donor milk than people realise.

“Donor milk is just so critical to the health of premature infants. It’s been shown to reduce the risk of necrotising enterocolitis (NEC), a severe and potentially fatal gastrointestinal infection common in premature babies. These infants are born with an underdeveloped gastrointestinal system, and breast milk is much more digestible than bovine-based formula.”

The American Academy of Paediatrics, as well as the World Health Organization, recommend donor milk from a human milk bank ahead of formula. Carroll points out donor milk is not actually about replacing a mother’s own milk, but more about filling the gap while the mother’s own milk supply is coming in. “In fact, conversations I’ve had with NICU mothers indicate many are grateful their baby can still get breast milk and avoid formula during what is a stressful and difficult time,” she says.

Rigorous screening processes are conducted by milk banks to ensure donor milk is safe for use.
“With critically ill tiny infants, who weigh maybe 500 grams, you need to be absolutely sure the milk has no medications or disease in it. Milk donors are screened more thoroughly than blood donors in terms of lifestyle factors, diet and contagious diseases such as HIV and Hepatitis B and C.”

She says donors aren’t allowed to smoke and are limited in the prescription medications they can take – they’re even questioned over herbal supplements and teas.

“If the donor’s family or the donor herself is sick, she has to wait until they’re well before expressing milk for donation to the milk bank. Then the milk itself is tested for bacteria before and after it’s pasteurised at 62.5 degrees celsius for 30 minutes. This deactivates even the HIV virus. There’s been no documented case of disease transmission as a result of donating human milk through the human milk bank system; it’s very safe.”

Umbilical Quad, NCIU, The Women’s Hospital, Indiana, USA

The use of donor milk also shows a substantial reduction in health care costs if NEC is prevented. The average cost per baby, per day in an NICU is between US$1000 and US$3000.

Further to this, if babies develop medical NEC, the hospital faces costs of US$75 000 to keep them alive, while more serious surgical NEC costs can reach US$200 000. Therefore, says Carroll, if the use of donor milk assists in reducing rates of NEC, both the additional costs and those associated with a longer hospital stay are avoided.

“For babies who only need on average 200 millilitres of donor human milk, the cost per baby, per stay is only US$27. And for the babies whose mothers do not produce breastmilk or do not wish to pump – and they’re in the minority of the cases I’ve studied – it comes to about 4.5 litres of donor milk, averaging US$590 per baby, per stay. So we’re not talking big dollars to save little lives. The savings made through the health system well and truly cover the costs of donor milk.”

Carroll is also looking at the milk donors themselves. She investigated the 76 donors who created enough milk for The Women’s Hospital’s NICU babies in Southern Indiana for one year.

“Eighty per cent of donors were married and 85 per cent had a minimum of a college education. One in three were health care workers ranging from neonatologists to registered nurses. One in five were in the field of education, such as teachers and professors. So they’re highly educated women in stable relationships.”

From the US, Carroll will travel to Norway where donor human milk is not pasteurised, leading her to look at the sociological aspects and acceptance of raw milk. She’ll then travel to Italy to observe their milk banking system before spending a final month in a recently opened NICU milk bank in Melbourne.

Upon her return to Sydney, Carroll plans to promote the importance of milk banking in NICUs throughout the community. She knows it will take time for cultural change and acceptance to occur, but hopes her research will help make the idea of donor human milk more digestible.

“I’d like to see donor human milk being made available to every NICU in Australia; that’s my aim. Whether that means each NICU needs its own milk bank, or the American model is adopted where you have centralised milk banks sending milk across towns and state boundaries.

“Too often the contribution of women to health care and our society is under recognised. Lactating women are producing this liquid gold and we don’t fully acknowledge its importance. Breast milk is literally a lifesaver.”