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Tuesday, May 17, 2011

Mother-to-mother human-milk sharing: what’s not to like?

This is a fantastic guest post from, James Akre. I'm hoping to have lots more of his amazing words to post here in the future!!! 

In May last year I was privileged to deliver the GOLD10 inaugural presentation, which was called: What is the problem with breastfeeding? I concluded with ten proposals for immediate action, for example the need to stop referring to breastfeeding as ‘best feeding’ and define it rather as ‘normal feeding’; and to cease talking about ‘the benefits of breastfeeding’ and focus instead on ‘the risks of not breastfeeding’.

My next-to-last proposal was in two parts: evaluating ‘the amount and value of human milk produced and consumed worldwide’, and ensuring that ‘human-milk banks become a routine component of healthcare infrastructure everywhere’.

The model I had in mind was the classic community blood bank. In a bit more than a century since such banks began functioning, they have become as ordinary as they are indispensable.

I don’t know how you see it, but from both a practical and historical perspective, what began to surface only six months ago – Internet-based, non-commercial, mother-to-mother human-milk sharing – strikes me as being a bit like the fall of the Berlin Wall in 1989 or the Arab Awakening of 2011.

If you think I’m being melodramatic, consider the totally unforeseen consequences of the act of one mother, in October 2010, searching on line for breast milk for her child. Here we are, six months later, with a vast and still-growing milk-sharing system in place in some 50 countries on all continents.

Despite its popularity – indeed, owing to its popularity – this contemporary variation on a practice that is as old as our species has become the focus of stern criticism and woeful warning from public health authorities, notably Health Canada, the French agency Afssaps, and the United States Food and Drug Administration. What is going on here? This is how I would describe the current state of play.

On the one hand, media reports suggest a convergence of well-informed and highly motivated women extending their control over the availability and use of human milk. Caregivers of babies who need breast milk are connecting with mothers who are able to donate breast milk using two Facebook-based networks, Eats On Feets and Human Milk 4 Human Babies.

These networks provide a platform for women to share their milk in a safe, ethical manner. This is done in the belief that they are capable of making informed choices, free of coercion; taking into account information on the benefits and risks; and reducing exposure to pathogens, including by pasteurisation. The overriding operative principle is that all who are involved in milk-sharing take full responsibility for their individual course of action and its outcome.

On the other hand, the formal position staked out by some public health authorities and health professionals can be summarised in three short words: Just say no! Why this dogmatic view?

Well, for starters, it’s the easiest way to reduce to zero milk-sharing’s inherent health risks. But this approach fails to take account of the inherent health risks of a child not receiving breast milk, which appear to have got entirely lost in the shuffle. It is rather a question of relative risk and how to manage it and minimise potential harm.

Despite the mass of scientific and epidemiological evidence to the contrary, in far too many environments breast milk and breastfeeding continue to be seriously undervalued, even as the nutritional merits and supposed safety of infant formula are greatly exaggerated. In these circumstances, infant formula is perceived as the ‘obvious’ alternative to a mother’s milk. But as we observe the rapid, and geographically and culturally diverse, expansion of mother-to-mother human-milk sharing, it is clear that growing numbers of mothers are radically dissenting from this unphysiological status quo.

In demonstrating their heightened awareness about how their babies should be nourished, these mothers are also giving eloquent expression to the World Health Organization’s infant-feeding recommendation, with its explicit nutritional hierarchy, that has been in place since 1986: milk at the mother’s breast; expressed milk from a baby’s own mother; milk from another healthy mother; banked human milk; and, lastly, infant formula. This is just one of the reasons why I always define formula not as the best alternative to a mother’s milk but as the least-bad alternative.

It’s hardly surprising that some in the public health and medical establishment regard this Internet-based milk-sharing model as a challenge, even a threat. It certainly has the right ingredients: a system that operates outside its influence, that can’t be regulated, and where mothers alone exercise control. But rather than resisting and dismissing it out of hand, the constructive approach would be to engage in ways that help make it as safe as possible.

Before closing I would like to return briefly to what I said, during GOLD10 and a few minutes ago, about ensuring that ‘human-milk banks become a routine component of healthcare infrastructure everywhere’. In the light of the mother-to-mother milk-sharing model described above, I want to assure you that I am no less enthusiastic about this proposal today than I was a year ago. If anything, I think it has become still clearer to me why it is so important.

It is at best naïve and uninformed, and at worst intellectually dishonest and culpable, to discourage mother-to-mother milk sharing while instructing mothers to stick with traditional human-milk banks, which follow a careful protocol designed to protect babies. Reality contradicts this dismissive injunction. According to reports, on a good day milk banks manage to cover no more than half the actual demand. Thus, they wisely husband available milk for the most vulnerable babies, especially the very sick and premature. But at US$3-5 a fluid ounce or about 30 ml, even if milk were available, few parents could afford such luxury.

Some observers appear to be anxious that mother-to-mother milk sharing threatens the few under-supplied banks. I don’t have the evidence to demonstrate it, but I am inclined to believe that expanding direct human-milk sharing might well spur human-milk banking by increasing awareness of the significance and availability of women’s milk, persuading more mothers to donate, and thereby increasing the number of banks and available milk volume.

Thus, I see mother-to-mother milk sharing as complementary to donor milk banking and not its competitor. Let us resolve to do everything we possibly can to ensure that this is always the case.

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1 Commentary prepared by James Akre, Geneva Switzerland, and delivered on line during GOLD11 (Global Online Lactation Discussion) on 13 May 2011