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1. HUMAN MILK BANKING Mrs. DEVU CHANDANA R CLINICAL INSTRUCTOR HOLY CROSS COLLEGE OF NURSING, KOTTIYAM, KOLLAM

2. introduction Breastfeeding is best method of infant feeding, because human milk continues to be the only milk which is uniquely suited to the human infant. In our country the burden of low birth weight babies in various hospitals is about 30% to 40% with significant mortality and morbidities feeding these babies with breast milk can significantly reduce the risk of infections. 19-07-2023 HUMAN MILK BANKING 2

3. When a mother, for some reason, is unable to feed her infant directly, her breastmilk should be expressed and fed to the infant. If mother‘s own milk is unavailable or insufficient, the next best option is to use pasteurized donor human milk (PDHM). 19-07-2023 HUMAN MILK BANKING 3

4. Worldwide, 4 million babies die each year in their first four weeks of life. This represents more than 10,000 deaths per day. Most neonatal deaths occur at the very beginning of life; three-quarters of them occurring within one week of birth. 19-07-2023 HUMAN MILK BANKING 4

5. In addition, the availability of donor breast milk is very significant for infants whose mother cannot breastfeed because of medical problems such as maternal open pulmonary tuberculosis, cancer chemotherapy, HIV and other viral infections. To fulfil this need, establishing donor breast milk banking is crucial. 19-07-2023 HUMAN MILK BANKING 5

6. India faces its own unique challenges, having the highest number of low birth weight babies, and significant mortality and morbidity in very low birth weight (VLBW) population Hence the Government, health experts and the civil society must join hands to propagate the concept of human milk banking for the sake of thousands of low birth weight and preterm babies. 19-07-2023 HUMAN MILK BANKING 6

7. history Human milk banking is the process by which breast milk is collected, screened and pasteurized for the use of hospitals or mothers who cannot breastfeed. The first human milk bank was found in 1909 in Vienna, Austria, and shortly afterwards in Boston, United States of America. Currently, many milk banks have been opened all over the world to minimize infant feeding problems. 19-07-2023 HUMAN MILK BANKING 7

8. Human milk is the best source of nutrition for all newborn babies. More specifically, a mother‘s breast milk is the first choice of nutrition for those who are preterm, have low birth weight, are unwell and for those vulnerable infants in the Neonatal Intensive Care Unit (NICU). 19-07-2023 HUMAN MILK BANKING 8

9. SPACE REQUIREMENT FOR MILK BANK There is no standard recommended size for a milk bank. The minimum requirement is a partitioned room of 250 square feet that can comfortably lodge at least the equipment required for milk banking, a work area for the technician as well as some storage space for records, administration and area for counselling donors etc. 19-07-2023 HUMAN MILK BANKING 9

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11. SPACE REQUIREMENT FOR MILK EXPRESSION/COLLECTION It is recommended to have an area earmarked for milk expression and collection where mothers can express milk comfortably. It can be either in the area adjacent to NICU or post natal wards or in the well-baby care follow up OPD. Privacy is of paramount importance. Provision of music/television and a crèche helps in reducing 15 stress of mothers. Teaching videos of KMC, expression of breast milk and advantages of breastmilk feeding can be shown under supervision of milk bank staff. 19-07-2023 HUMAN MILK BANKING 11

12. PASTEURIZER/ SHAKER-WATER BATH It is essential to have a device to carry out heat treatment of all available donor milk at the recommended temperature of 62.5°C for a period of 30 minutes (Holder pasteurization) prior to its use. This can be achieved using a conventional pasteurizer. However a conventional pasteurizer is extremely expensive and generally of dairy industry size and is often not suitable for the quantity of milk to be pasteurized in a human milk bank. 19-07-2023 HUMAN MILK BANKING 12

13. EQUIPMENTS FOR FLASH HEAT TREATMENT Where pasteurizer is not available, an effective low cost alternative called flash heat treatment can be used for pasteurization. This has been shown to inactivate HIV in donated breast milk samples and has been found to be nutritionally safe as well. 19-07-2023 HUMAN MILK BANKING 13

14. DEEP FREEZER A deep freezer to store the milk at -200 C is essential in the milk bank. This may be a vertical model with refrigerator-like shelves. Such models are available in larger sizes of 285 to 300 liters. For smaller capacity deep freezers, the horizontal models with racks can also be used. 19-07-2023 HUMAN MILK BANKING 14

15. two deep freezers for processed milk First for storage awaiting culture: It is used for storage of the milk till the post pasteurization milk culture reports are available. The second deep freezer is used for storage of the pasteurized milk once the culture reports are available and are negative and the milk is considered safe for disbursement. 19-07-2023 HUMAN MILK BANKING 15

16. REFRIGERATORS Separate refrigerators are required for: To store the milk till whole day‘s collection is over and ready to be mixed for further processing. (In case where separate deep freezer is not available for this purpose) Thawing the milk that is to be dispatched for use. 19-07-2023 HUMAN MILK BANKING 16

17. HOT AIR OVEN / AUTOCLAVE A hot air oven / autoclave in the milk bank or centralized service is essential for sterilizing the containers used for collection from donors, containers for pasteurizing and storing the milk, and the test tubes needed for sending milk culture samples to the microbiology lab. CSSD facility of the hospital can be utilized for this purpose. 19-07-2023 HUMAN MILK BANKING 17

18. GENERATOR / UNINTERRUPTED POWER SUPPLY Every milk bank should have a dedicated source of uninterrupted power supply in the form of a generator, UIPS or inverter to run the deep freezers & refrigerators in case of electricity failure. 19-07-2023 HUMAN MILK BANKING 18

19. ADDITIONAL DESIRABLE EQUIPMENTS It is desirable to have a milk analyzer using infra-red spectroscopy technology, for macro nutrient analysis of breastmilk to estimate the calorie, protein & fat of a milk sample, in teaching hospitals as a step towards lacto engineering. 19-07-2023 HUMAN MILK BANKING 19

20. EQUIPMENT REQUIRED AT SITE OF MILK EXPRESSION & COLLECTION 19-07-2023 HUMAN MILK BANKING 20

21. EQUIPMENT REQUIRED AT SITE OF MILK EXPRESSION & COLLECTION BREASTMILK PUMPS CONTAINERS FOR MILK COLLECTION & STORAGE Polythene milk storage bags Hard plastic containers Stainless steel containers Glass containers 19-07-2023 HUMAN MILK BANKING 21

22. ADMINISTRATION AND STAFF OF THE MILK BANK 19-07-2023 HUMAN MILK BANKING 22

23. ADMINISTRATION AND STAFF OF THE MILK BANK THE DIRECTOR MILK BANK OFFICER /CHIEF OPERATING OFFICER LACTATION MANAGEMENT NURSES MILK BANK TECHNICIAN MILK BANK ATTENDANT MICROBIOLOGIST RECEPTIONIST CUM RECORD KEEPER 19-07-2023 HUMAN MILK BANKING 23

24. GENERAL GUIDELINES FOR STAFF Gloves should be worn and changed between handling raw and heat-treated milk. Staff should follow hygienic practices like proper hand wash, donning gowns, mask, gloves, trimming nails, locking long hairs. Staff should undergo regular health checks and be immunized against Hepatitis-B. 19-07-2023 HUMAN MILK BANKING 24

25. COST APPROXIMATION OF SETTING UP & RUNNING A MILK BANK Deep Freezer: Rs.40,000 to 1 lakh Pasteurizer: Rs. 40,000 to 1 lakh Refrigerator: Rs. 25,000 Milk Pumps with adequate lacta sets: Rs. 60,000 to Rs. 1 lakh Hot air Oven: Rs. 50, 000 UPS / generator: 1 to 2 lakh. Total: 3 to 6 lakhs. Recurring Cost: Staff salaries - 10 to 12 lakhs per year. No financial incentives to donors, no cost to recipients 19-07-2023 HUMAN MILK BANKING 25

26. LEGAL AND ETHICAL ISSUES RELATED TO HUMAN MILK BANKING ARE: Establishment of human milk bank Payments to the donor Commercialization of human milk bank Claims on transmission of infection: Religious issues Duration of keeping records of the donors and recipients. 19-07-2023 HUMAN MILK BANKING 26

27. DONOR MANAGEMENT 19-07-2023 HUMAN MILK BANKING 27

28. Donor Population The mothers, who are lactating and willing to give extra breast milk for other babies without compromising the nutritional needs of their own baby, form the donor population. Mothers who have babies admitted in the neonatal unit or wards, Mothers who come to attend outdoor department for well-baby care, immunizations and other ailments, 19-07-2023 HUMAN MILK BANKING 28

29. Donor Population Lactating staffs working in the hospital, Mothers who have lost their babies or cannot give milk to their own babies due to some reason but are willing to donate their breastmilk voluntarily, Lactating mothers motivated by community and other awareness means. Human Milk Banks should have policy of taking breast milk donations on voluntary basis. Donors are not paid for their donation. 19-07-2023 HUMAN MILK BANKING 29

30. Counseling and Motivating Maximum donor population should be reached using variety of avenues. Spreading awareness about possibility of breast milk donation in society by various means of mass communication can help motivating donors. 19-07-2023 HUMAN MILK BANKING 30

31. Possible routes of recruiting donors can be: Those who have already donated and by their recommendation Staff of NICU/PNC ward/Pediatric clinics Pregnancy and child birth educators/counselors and their class attendees Breastfeeding support groups especially women‘s social clubs Mass Media 19-07-2023 HUMAN MILK BANKING 31

32. The donor mothers should be counseled regarding: The need and efficacy of donated human milk and its benefits to the recipient baby without harming her own baby, Donor evaluation prerequisites: the process of screening, giving authentic medical records, serologic testing and her physical examination for medical conditions mentioned in donor selection criteria, 19-07-2023 HUMAN MILK BANKING 32

33. The donor mothers should be counseled regarding: Procedure of consent, Process of breast milk collection, transport to the milk bank, processing, storage and disbursal of donated milk to the needy babies, Maintenance of lactation and tackling with problems related to it. 19-07-2023 HUMAN MILK BANKING 33

34. Consent After counseling and motivating donor mother‘s written informed consent should be obtained. Donor mothers should know about the process of milk donation, medical screening and serologic testing and have to understand that they have no claim over the donated milk once donated. Records need to be maintained for 5 years as recommended by blood banks5. 19-07-2023 HUMAN MILK BANKING 34

35. Screening After counseling, motivation and consent, the donor mothers should be screened for suitability of donation by reviewing her health records and asking relevant questions regarding criteria mentioned in the section of donor selection below. The following should be enquired and documented before breast milk collection in a donor screening Performa. 19-07-2023 HUMAN MILK BANKING 35

36. Health of the donor mother‘s own baby. Historical data of drug intake, smoking, exposure to chemicals, high risk behavior and other data mentioned in donor selection section. It can be done through a questionnaire given to mother and filled by her with help of trained person. Examination of local breast lesions and disease states of mother to ensure eligibility as given below in section of donor selection. Serological screening. 19-07-2023 HUMAN MILK BANKING 36

37. DONOR SELECTION Donor mothers must: Be in good health and health related behaviours . Not be regularly on most medications or herbal supplements (with the exception of postnatal vitamins, human insulin, thyroid replacement hormones, nasal sprays, asthma inhalers, topical treatments, eye drops, progestin-only or low dose oestrogen birth control products). 19-07-2023 HUMAN MILK BANKING 37

38. DONOR SELECTION Be willing to undergo blood testing for screening of infections. (Usually it is at the milk bank‘s expense). Have enough milk after feeding her baby satisfactorily and the baby is thriving nicely. 19-07-2023 HUMAN MILK BANKING 38

39. A woman would NOT be a suitable donor if she: Uses illegal drugs. Smokes or uses tobacco products or nicotine replacement therapy. Regularly takes more than two ounces of alcohol or its equivalent per day or more than three caffeinated drinks (total of about 150 to 200 mL) daily. Has a positive blood test result for HIV, HTLV, Hepatitis B or C, or Syphilis. 19-07-2023 HUMAN MILK BANKING 39

40. Has high risk behavior for HIV transmission. Had a sexual partner at risk for HIV, HTLV or Hepatitis and venereal diseases in the past 12 months: a. Including anyone with hemophilia or anyone who has used a needle for injection of illegal or non-prescription drugs. Has received organ or tissue transplant, any blood transfusion/blood product within the prior 12 months. 19-07-2023 HUMAN MILK BANKING 40

41. Is taking radioactive drugs. Has chemical environmental exposure known to be toxic to the neonate and excreted in breastmilk. Have active lesions of herpes or chickenpox on the breast. Daily uses over-the-counter medications or systematic prescription not permitted for donor milk. For medication compatibility/safety with breastfeeding checks out with standard literature. Medical advice should be on the side of caution 19-07-2023 HUMAN MILK BANKING 41

42. Temporary disqualification Active donors are temporarily disqualified from donating milk under the following conditions: Any acute infection, including clinical mastitis and monilial/fungal infections of the nipple or breast. During the 4 week period following a case of rubella or varicella in the household starting from when the lesions crust over. During the one week period following a reactivation of latent infection with HSV or varicella zoster of the breast or thorax starting from when the lesions crust over. 19-07-2023 HUMAN MILK BANKING 42

43. During the 12 hour period following consumption of alcohol (hard liquor, beer or wine). During the 8 days following donors‘ or its partner‘s receipt of a tattoo administered in a regulated site using sterile needles and single-use only dyes. During 28 days following donors‘ receipt of live virus vaccine for measles, mumps and rubella. During the 3 months following receipt of any live virus vaccine including chicken pox, rotavirus, polio and typhoid. 19-07-2023 HUMAN MILK BANKING 43

44. Serological Testing All tests should be undertaken in a standard reliable laboratory and preferably in the same hospital where milk bank is established. Ensure that laboratories communicate the results of serological testing clearly and that they provide appropriate interpretative comments. 19-07-2023 HUMAN MILK BANKING 44

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46. LIST OF HUMAN MILK BANKS IN INDIA 19-07-2023 HUMAN MILK BANKING 46

47. Divya Mother Milk Bank, Udaipur, Rajasthan Amara Milk Bank (In collaboration with Fortis la Femme), Greater Kailash, New Delhi Lokamanya Tilak Hospital (Sion Hospital), Sion, Mumbai Vijaya Hospital, Chennai KEM Hospital, Parel, Mumbai, Deena Nath Mangeshkar Hospital and Research Centre, Pune Institute of Child Health, Egmore , Chennai Sir JJ Group of Hospitals, Byculla, Mumbai SSKM Hospital, Kolkata Cama Hospital, Fort, Mumbai Surya Maternity Hospital Mumbai 19-07-2023 HUMAN MILK BANKING 47

48. BENEFITS OF HUMAN MILK BANKING High quality human milk protein Enhanced fat absorption Improved absorption of lactose minerals Enhanced gastric emptying Unique species-specific ingredients promoting brain growth cognition Unique factors enhancing intellectual visual development 19-07-2023 HUMAN MILK BANKING 48

49. CONCLUSION Milk banks serve a vital function by providing human milk for premature infants who, for a variety of reasons, would otherwise not have access to human milk. As human milk confers major protective effects to premature infants, the availability of human milk is an important quality of care issue. The use of donor milk is widely endorsed. It is clear that artificial formula will never provide the broad range of benefits of human milk. 19-07-2023 HUMAN MILK BANKING 49

50. Given the high rate of preterm births in the country and level of malnutrition that ensues in the postnatal growth in such babies after birth, there is an urgent need to establish milk banks across the country, especially in the large neonatal units of all hospitals. 19-07-2023 HUMAN MILK BANKING 50

51. Breastfeeding promotion and the collection of donor breast milk are linked. By offering correct information about breastfeeding, women have an increased chance of successfully breastfeeding their infant. Having a human milk bank in a health facility increases awareness about breastfeeding among families and the community. 19-07-2023 HUMAN MILK BANKING 51

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