Something smells off and it's not the milk!

We learn at a pretty young age that milk left out on the counter, or too long in the fridge, goes off. I don't have a single child that doesn't eyeball the carton before they pour milk onto their cereal, and they give it a sniff if they're not sure. And if it's been sitting out? Nope, they're not touching it. In fact, my kids are very likely to go "eww" if a carton of yogurt has gone past its best before date, despite my protests: "It's yogurt, it's supposed to be full of bacteria. It's healthy bacteria! That's a BEST BEFORE date, it doesn't automatically go bad at midnight. Gaah!"

Yet, apparently, when my children become adults, and then parents, they will have lost every bit of wisdom they've learned growing up and they'll become incapable of determining how to safely feed their babies. They will have no capacity to distinguish between borrowing a cup of milk from the neighbour, and grabbing a carton that's open and been sitting in a dumpster.

At least, that seems to be the conclusion drawn by some after reading a new study published in Pediatrics today out of the Nationwide Children's Hospital in Ohio. Researchers looked at several hundred classified ads listing human milk for sale and offered to buy. They responded only "to ads from sellers who did not ask about the infant receiving milk and who did not require a phone call before a transaction was made" and directed sellers to ship the milk to a PO Box in Ohio. Some of the milk was shipped in a liquid state, some frozen milk wasn't protected during shipment and thawed before arrival, and it appears that some sat for as long as six days before being tested. Nobody knows how the milk was collected or stored. It's not clear if they even checked to be sure it was human milk as advertised. The study concludes the purchased milk:

"exhibited high overall bacterial growth and frequent contamination with pathogenic bacteria, reflecting poor collection, storage, or shipping practices. Infants consuming this milk are at risk for negative outcomes, particularly if born preterm or are medically compromised. Increased use of lactation support services may begin to address the milk supply gap for women who want to feed their child human milk but cannot meet his or her needs."

The results are not revolutionary. The milk of any species will rot if it's left to sit around in the heat. The study is meaningless when applied to the real world of moms who don't have enough breastmilk to feed their babies, unless we needed someone to tell us not to drink milk left lying around, or that shady characters = shady behaviour = increased risk.

I saw a copy of this study before it was published and it frustrated me greatly that the authors' conclusions were applied to peer-to-peer milksharing, even though the study has nothing to do with milksharing. Concerns expressed prior to publication have resulted in some wording changes and the final news release is clearer. Still, some people are pointing to this study and warning families not to purchase milk via the Internet, even though the study's methodology is hardly what families unable to access donor milk and turning to riskier milk purchase would employ. Others are saying milk that isn't from a milk bank is dangerous and are urging families to feed infant formula if they can't get screened milk. That is sound advice - but it ignores that families are quite capable of screening and even processing milk on their own.

These warnings may be well-intentioned, but they are incredibly disrespectful. Do families really need to be warned about this? Do families actually feed their children unscreened milk purchased from shady characters who ship to anonymous PO boxes? Of course not.

Researcher Karleen Gribble recently wrote:

"research by Thorley (Thorley, 2011) and myself (as yet unpublished) supports the proposition that recipient mothers of peer-to-peer shared milk take enormous care in deciding to feed their child the milk of another, and in managing the risks involved. Despite the absence of institutional involvement, there is nothing casual about the process. Mothers, however, would benefit from greater support from health workers in assisting them in their decision-making."

It would be much more valuable for researchers to explore how families who seek human milk for their children actually behave. How do they screen their sources? What kind of hygiene guidelines are out there for mothers who express their breastmilk for their own babies (because that is how most milk that winds up being made available for someone else's baby - it starts as a freezer stash intended for mom's own baby.)

And yes, families who have problems breastfeeding need greater support from health workers. Those health workers in turn need greater support from their guiding bodies. And Health Canada and the FDA and the like to get off the pot and adopt harm reduction strategies if they want to address concerns about feeding human milk that doesn't come from from a mother's breast directly to her baby's lips, and doesn't come from a milk bank.

If we're going to get all excited about milk selling, how about looking at the growing number of for-profit corporations out there offering to buy milk from moms so they can create highly formulated human milk products for sale to hospitals.

US company Prolacta milks donors, charity partners

Because that's what stinks about this whole issue. Some would have you believe that milk from the mom-next-door is "dirty" and not fit to be fed to babies. But at the very same time, slick marketing campaigns are convincing the same mom that her milk is a scarce and precious commodity that will save the lives of babies.

Same moms. Same milk.

A selection of news coverage:

Breast intentions? New study spurs debate over online breast milk sales -- Verge.com, Oct 21, 2013
Is it really possible to purchase breast milk online? - Huffington Post, Oct 21, 2013
Breast milk donated or sold online is often tainted, study says -- New York Times, Oct 21, 2013
Online milk sharing carries health risks from bacterial contamination: study -- New York Daily News, October 21, 2013

Significant corporate developments in the US human milk marketplace

The founder of Prolacta Bioscience, an oft-criticized company that uses breastmilk given for free by moms to produce products it sells for profit to hospitals –for premature infants – has started a competing company.

Elena Medo says she sold her stock last year in Prolacta and says "worldwide the only competition have is my old company."

Medolac Laboratories (Neolac) will sell human-milk derived fortifier and other human-milk based products for use in both hospitals and at-home use. Prolacta, which recently expanded its facility to allow it to store as much as 110,000 litres of frozen human milk, sells its fortifier at a price of $6.25/ml, or $185/ounce.

Medo has secured suppliers of human milk by partnering with two organizations:

Current ads on Only The Breast, Oct. 20, 2013

•  Only The Breast, which up until now has operated an Internet-based classified ad human milk selling site, said in a news release Friday it is abandoning that model and will work to direct its stable of sellers to Medo's new firm. Of note, Only The Breast is under fire in a soon-to-be published research report published Oct. 21 which found high rates of bacteria in samples purchased from people selling human milk from its site.

Image from Mothers Milk Cooperative website.

• Mothers Milk Cooperative, founded in May 2013 and described by Medo as a "sister company" that will provide the "supply-side" for Medolac, allows women to donate in a "Pay It Forward" model, or to directly sell their milk for "Milk Money" at $1/ounce. Mothers Milk Cooperative plans to set up hospital-based milk bank sites.

The ethical problems with Prolacta's model are obvious. The jury's still out on Medo's new model.

Sources: Interview with Medo, August 2013
PRNewswire, Medolac Laboratories and Mothers Milk Cooperative announce agreement 
Elena Medo Linked-In Profile
News Release, Only The Breast announces innovative new milk banking partnership - Oct 18 2013 (via a receiving journalist)

-----

Previous Human Milk News posts on Prolacta.

Previous Human Milk News post on Only The Breast.

WHO Code training in Toronto

IBFAN's International Code Document Centre
experts talk about historical efforts to
curb deadly infant formula marketing,
and how it lead to the WHO/UNICEF
move to create the
International Code of Marketing
of Breastmilk Subsittudes

I have just completed a three day training workshop on how to monitor for violations of the International Code of Marketing of Breastmilk Substitutes. I plan to blog in more detail shortly. For now, please take a look at the daily summaries of the live-tweets from the workshop (and follow #WHOCode and #nonestle on Twitter for ongoing updates on Code issues and actions.) If you are interested in a little more of history of how the Code was created, see this YouTube excerpt of the 1984 BBC film, "When Breasts are Bad for Business."

Health Canada still warns against milksharing, families still share milk through HM4HB

CBC's Windsor, Ontario outlet has a feature interview and web article today on families who donate or receive milk through the Human Milk 4 Human Babies Southwest Ontario Facebook page. 

CBC Windsor website, March 15, 2013

CBC reports Health Canada has reiterated its years-old alert which was originally issued to warn Canadians about the dangers of purchasing human milk from strangers on Craigslist. 

Families are increasingly ignoring Health Canada's warning, and similar warnings from the US, France, and other authorities about the possible risks of milksharing. HM4HB networks across Canada are facilitating thousands of what they call "milky matches" between families in need and mothers with excess. When breastfeeding advocates started to move away from simply echoing infant formula company's "breast is best" messaging, and started to talk instead about the risks of infant formula, they provided the fuel for families to think hard about to donor milk as a possibly less risky option when breastfeeding fails.

Offers and asks, HM4HB Vancouver

Milksharing advocates responded to the warning in 2010: 

If Health Canada is to recommend anything to Canadian women about the practice of sharing milk, which is a food, please recommend evidence-based procedures for them to follow for the safe sharing of human milk. 

A growing number of people talking about the need for guidance for milksharing families, not warnings. Australia's Dr. Karleen Gribble wants health authorities to move away from proscription. Gribble says it's unethical for health authorities to provide warnings instead of guidance, and I agree (see my blog post of January 2012.) During World Milksharing Week 2012 several lactation consultants and peer counsellors also wrote about the need for guidance and advice.

In addition to the explosion in milksharing, more of Canada's sick, hospitalized babies are also finally receiving donor human through milk banks in Calgary and Toronto. And the availability of milk for the sickest premature babies in hospital is causing families to ask why this need isn't also being met in the community. At the same time, milk banks are concerned the practice of milksharing may be eroding their donor supply.

From the CBC interview:

“Women are just trying to help each other out,” said Margaret Deneau, who owns Sweetheart Baby Boutique in Windsor. “I think it’s wonderful that there is a place for you to get milk for your baby if you can’t produce it yourself.

“It makes me sad it has to be done privately. It would be nice if the region provided it and the moms didn’t have to go underground to do it.”

Over the last few years Canada's paediatricians and Health Canada have begun work on a loose policy framework that acknowledges donor human milk's value both in the NICU and in the community.

Health Canada's new Nutrition for Healthy Term Infants guidelines, produced jointly with the Canadian Paediatric Society, Dieticians of Canada, and the Breastfeeding Committee for Canada, says (and note this is for healthy infants from zero to six months):

For infants who cannot or should not be fed their mother's breastmilk, pasteurised human milk from appropriately screened donors and commercial infant formula are suitable alternatives. These options depend on individual circumstances.

The Canadian Pediatric Society 's position paper on donor human milk says:

When the mother’s own milk is unavailable for the sick, hospitalized newborn, pasteurized human donor breast milk should be made available as an alternative feeding choice followed by commercial formula. 

Health Canada goes on to say: 

Breastmilk from appropriately screened donors must be properly collected, pasteurized, and stored. The only way to ensure this is to obtain the breastmilk from a milk bank that is operated under the Human Milk Bank Association of North America Guidelines.  

And Health Canada echoes the Canadian Paediatric Society's concern that if there isn't enough human milk for the human babies who need it, priority must be given to the most fragile babies in the system.

Hospitalised infants who will get the most benefit have highest priority for this milk.

Instead of warning families away something they're clearly going to do anyway, Canada can take a leadership role by strenghening both this policy framework and our support systems for the use of donor human milk. We must respond to growing demand from families for donor human milk instead of infant formula when mother's own milk isn't available. What can be done?:

• We can step up our efforts to ensure mothers who want to breastfeed are properly supported in hospital and in the community, reducing the need for supplementing and increasing our supply of potential donors.

• We can formally endorse milk banks and give them access to funding and resources to both better attract donors and to offset the financial costs of milk donation. (Breast pumps and collection bottles are expensive, and so is shipping and maintaining drop-off depots.) 

• We can review milk bank screening and processing guidelines to ensure we are not being overly restrictive (for example due to lingering BSE concerns we still don't allow donors who have spent time in the UK - yet those moms could donate to UK milk banks.)

• Processing and pasteurizing donor human milk is expensive but cost-effective for premature babies who can become ill or die, racking up tens of thousands in treatment costs along the way. But healthy babies may not need highly processed milk. Canada can explore the use of unpastuerized milk from screened mothers when healthy babies have a medical need to be supplemented, both in hospital and in the community. 

• We can create evidence-based guidelines for the safer peer-to-peer sharing of milk in the community.