Maintaining safety and service provision in human milk banking: a call to action in response to the COVID-19 pandemic
Authors: Natalie Shenker, Joao Aprigio, Sertac Arslanoglu, Nant San San Aye, Anne Bærug, Naomi Bar Yam, Debbie Barnett, Roopa Bellad, Enrico Bertino, Adhisivam Bethou, Ketan Bharadva, Anne Bille Olin, Claude Billeaud, Rachel Buffin, Tanya Cassidy, Ruchika Chugh Sachdeva, Vanessa Clifford, Anna Coutsoudis, Sila Deb, Andreja Domjan, Li-Jung Fang, Janette Festival, Anthea Franks, Nadia Garcia-Lara, Antoni Gaya, Branka Golubiú-Úepuliú, Lindsay Groff, Anne H Grøvslien, Erin Hamilton Spence, Mohammad Heidarzadeh, Mohammadbagher Hosseini, Jackie Hughes, Kiersten Israel-Ballard, Kajal Jain, Suksham Jain, Selvaraj Jayaraman, Frances Jones, Pratibha Kale, Jayendra Kasar, Angela Kithua, Laura Klein, Daniel Klotz, Yungchieh Lin, Xihong Liu, Laraine Lockhart Borman, Josefin Lundstrom, Andreas Malzacher, Kimberly Mansen, Roger Mathisen, Radmila Mileusnic-Milenovic, Zaw Win Moe, Guido Moro, Suchandra Mukherjee, San San Myint, Sushma Nangia, Sopapan Ngerncham, Faith Njeru, Estrella J Olonan-Jusi, Gillian Opie, Aunchalee Palmquist, Penny Reimers, Maryam Saboute, Pauline Sakamoto, Sybil Sanchez, Natalie S Shenker, Himabindu Singh, Jai Singh, Poonam Singh, Marta Staff, Christine Sulfaro, Tran Thi Hoang, Annika Tiit-Vesingi, Satish Tiwari, Johannes B van Goudoever, Amy Vickers, Mary Waiyego, Gillian Weaver, Aleksandra Wesolowska, Jenny Wright
Journal: The Lancet Child & Adolescent Health (2020)

When a mother's own milk is not available, WHO recommends pasteurised donor human milk as the first alternative.1WHODonor human milk for low-birth-weight infants.https://www.who.int/elena/titles/donormilk_infants/en/Date: 2019Date accessed: April 30, 2020Google Scholar Human milk banks screen and recruit donors, and have wide-ranging precautions to ensure the safety of donor milk. Screened donor milk principally feeds babies of very low birthweight, protecting them from a range of complications,2Quigley M Embleton ND McGuire W Formula versus donor breast milk for feeding preterm or low birth weight infants.Cochrane Database Syst Rev. 2019; 6CD002971Google Scholar as well as babies with congenital anomalies or neurological conditions.3El-Khuffash A Jain A Lewandowski AJ Levy PT Preventing disease in the 21st century: early breast milk exposure and later cardiovascular health in premature infants.Pediatr Res. 2020; 87: 385-390Crossref PubMed Scopus (23) Google Scholar, 4Hoban R Khatri S Patel A Unger SL Supplementation of mother's own milk with donor milk in infants with gastroschisis or intestinal atresia: a retrospective study.Nutrients. 2020; 12: 589Crossref Scopus (20) Google Scholar, 5Tully MR Lockhart-Borman L Updegrove K Stories of success: the use of donor milk is increasing in North America.J Hum Lact. 2004; 20: 75-77Crossref PubMed Scopus (25) Google Scholar The benefits of a human milk diet highlight the importance of providing these infants with donor milk for short periods—with appropriate use in the context of optimal support for lactation, such provision can support mothers to establish their milk supply without the need for supplementation with infant formula milk.6Kantorowska A Wei JC Cohen RS Lawrence RA Gould JB Lee HC Impact of donor milk availability on breast milk use and necrotizing enterocolitis rates.Pediatrics. 2016; 137e20153123Crossref PubMed Scopus (157) Google Scholar The coronavirus disease 2019 (COVID-19) pandemic is presenting many challenges to human milk banks worldwide and highlights a range of vulnerabilities in service provision and emergency preparedness. For the first time, the global human milk bank community is coming together to share learnings, collaborate, and plan. A Virtual Communication Network of milk bank leaders started to form on March 17, 2020, and now has more than 80 members from 34 countries. Data collated from regional and country leads in the Virtual Communication Network show that more than 800 000 infants are estimated to receive donor milk worldwide annually. However, the inadequate quality of the data is a major flaw, and the true global scale of milk banking is unknown. The group actively discusses COVID-19-specific challenges and has developed mitigation strategies to ensure donor milk safety and service continuation, which will shortly be made available as a publication. During this crucial COVID-19 response period, human milk banks are facing the logistical challenges of adequate staffing, difficulties in donor recruitment, questions around the safe handling and transportation of donor milk, and increased demand as a result of mothers and infants being separated. The global nature of this network supports breastfeeding advice from WHO, which is appropriate in both low-income and high-income nations.7WHOBreastfeeding advice during the COVID-19: for health care workers.https://www.who.int/docs/default-source/maternal-health/faqs-breastfeeding-and-covid-19.pdfDate: 2020Date accessed: April 30, 2020Google Scholar Human milk bank leaders who have lived and worked through the HIV pandemic have brought insights into the mistakes that occurred in the 1980s, with fear leading to breastfeeding cessation and costing the lives of many babies who received infant formula in unsafe conditions.8Moland KM de Paoli MM Sellen DW van Esterik P Leshabari SC Blystad A Breastfeeding and HIV: experiences from a decade of prevention of postnatal HIV transmission in sub-Saharan Africa.Int Breastfeed J. 2010; 5: 10Crossref PubMed Scopus (35) Google Scholar Unlike HIV, where transmission via breastfeeding was a source of infection, there is no evidence around severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission from breastfeeding or human milk,9Chen H Guo J Wang C et al.Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records.Lancet. 2020; 395: 809-815Summary Full Text Full Text PDF PubMed Scopus (2656) Google Scholar and the virus is inactivated by heat treatment.10Chin AWH Chu JTS Perera MRA et al.Stability of SARS-CoV-2 in different environmental conditions.Lancet Microbe. 2020; (published online April 2.)https://doi.org/10.1016/S2666-5247(20)30003-3Summary Full Text Full Text PDF Scopus (1191) Google Scholar Similar patterns have emerged during other viral outbreaks (eg, Zika in 2016), where uncertainty about donor milk use meant that milk was withheld, and then used again once pasteurisation was proven to be effective or the virus shown not to be transmissible through milk. In the meantime, vulnerable infants have received suboptimal care. This constraint does not affect similar services (eg, blood transfusion and organ transplantation) to the same extent, where oversight and rapid research are prioritised. To avoid further straining the health system during the COVID-19 pandemic, the best chance to keep infants healthy is to promote breastfeeding and a human milk diet. WHO notes that where donor milk provision can play a part, human milk bank services should be supported. The consensus from this Virtual Communication Network is that a comprehensive approach should be implemented to maintain contact between mothers and babies, with skin-to-skin contact and breastfeeding support. If donor milk is provided during any separation linked to COVID-19, this should be for as short a time as possible as a bridge to receiving mother's own milk. By reducing the amount of mother–infant separation time and supporting the use of mother's own milk, the excess demand for donor milk will diminish, ensuring that the global supply can continue to be used for those who need donor milk most, when maternal breastfeeding is disrupted or not possible. This approach increases the chances that these infants will leave the neonatal intensive care unit breastfeeding exclusively, which is essential for the long-term health of mother and baby. Emphasis on the importance of human milk for infants within neonatal units creates an environment where the mother's own milk is seen as the valuable lifesaving resource that it is. It is imperative that human milk bank systems are not inadvertently affected by efforts to contain COVID-19, but milk banks are facing unprecedented challenges to maintain safe supplies in volatile health system infrastructures. Local issues have been deepened by the absence of globally agreed operational safety guidelines, no global mechanism for rapid communication among milk banks, with little data and infrastructure to ensure responsiveness during a crisis. The strengthening of human milk bank systems is required to ensure that safe provision of donor milk remains an essential component of early and essential newborn care during routine care or emergency scenarios, such as natural disasters and pandemics. We therefore collectively call on global policy leaders and funding agencies to recognise and prioritise the need to address four high-impact areas: (1) ensuring neonatal nutrition is an essential focus during emergencies; (2) funding research to optimise human milk bank systems in response to new infectious threats; (3) investing in innovation across all aspects of milk banking processes to improve the responsivity, access, and quality of donor milk provision; and (4) supporting the integration of learnings and innovations by the global milk bank community during COVID-19 into newborn, nutrition, and emergency response planning for future emergencies. The Virtual Communication Network is now focused on building a formal global alliance to enable enhanced communication, sharing of data, and maintenance of optimal practices. Human milk banks constitute a necessary but chronically under-resourced service that deserves better protection against this and future emergencies. NS reports funding from UK Research and Innovation, as a Future Leaders Fellow at Imperial College London; and is a cofounder and trustee of the Human Milk Foundation. All other authors declare no competing interests. Download .pdf (.22 MB) Help with pdf files Supplementary appendix