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Human Milk Banking: Straight from the heart to beat the odds

Human Milk Banking: Straight from the heart to beat the odds . Penny Reimers RN RM IBCLC. Outline. Introduction Benefits of Donor Milk/ Uses Donor Mothers Human Milk Banks in South Africa International Breastmilk Project Current Research Heat Treatment Donor Milk and Health Policy

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Human Milk Banking: Straight from the heart to beat the odds

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  1. Human Milk Banking:Straight from the heart to beat the odds Penny Reimers RN RM IBCLC

  2. Outline • Introduction • Benefits of Donor Milk/ Uses • Donor Mothers • Human Milk Banks in South Africa • International Breastmilk Project • Current Research • Heat Treatment • Donor Milk and Health Policy • International Trends • HMBASA • Conclusion P. Reimers IBCLC

  3. Introduction • What is Milk Banking? • It is a service which screens, collects, processes and dispenses human milk that has been donated by volunteer nursing mothers who are not related to the recipient infant. • Every effort should be made to feed fresh breast milk to a mother’s own infant • Donor Milk is 1st alternative – WHO & UNICEF 1980/2003 • Part of comprehensive b/f programme- Protects, promotes, supports b/f P. Reimers IBCLC

  4. WHO-World Health Assembly 25 th May, 2008 Directive for countries to investigate the use of donor banking as a risk reduction strategy for infant mortality and morbidity and to do research to provide support on the safe use of donor milk P. Reimers IBCLC

  5. Slide of formula vs breastmilk P. Reimers IBCLC

  6. Antibacterial factors found in human milk- SecretoryIg A • E. coli (also pili, capsular antigens, CFA1) including enteropathogenic strains, C. tetani, C. diphtheriae, K. pneumoniae, S. pyogenes, S. mutans, S. sanguins, S. mitis, S. agalactiae(group B streptococci), S. salvarius, S. pneumoniae(also capsular polysaccharides), C. burnetti, H. influenzae. H. pylori, S. flexneri, S. boydii, S. sonnei, C. jejuni, N. meningitidis, B. pertussis, S. dysenteriae, C. trachomatis, Salmonella (6 groups), S. minnesota, P. aeruginosa, L. innocua, Campylobacterflagelin, Y. enterocolitica, S. flexneri virulence plasmid antigen, C. diphtheriae toxin, E. colienterotoxin, V. choleraeenterotoxin, C. difficile toxins, H. influenzae capsule, S. aureusenterotoxin F, Candida albicans*, Mycoplasmapneumoniae P. Reimers IBCLC

  7. Antibacterial factors found in human milk • Lactoferrin is active against: • E. coli, E. coli/CFA1 or S-fimbriae, Candida albicans*, Candida krusei*, Rhodotorula rubra*, H. influenzae, S. flexneri, Actinobacillus actinomycetemcomitans • Lipids active against: • S. aureus, E. coli, S. epidermis, H. influenzae, S. agalactiae, L. monocytogenes, N. gonorrhoeae, C. trachomatis, B. parapertusis heat-labile toxin, binds Shigella-like toxin-1 P. Reimers IBCLC

  8. Antibacterial factors found in human milk • Milk cells (80% macrophages,15% neutrophils,0.3% B and 4% T lymphocytes) active against: • By phagocytosis and killing: E. coli, S. aureus, S. enteritidisBy sensitised lymphocytes: E. coliBy phagocytosis: Candida albicans*, E. coliLymphocyte stimulation: E. coli K antigen, tuberculinSpontaneous monokines: simulated by lipopolysaccarideInduced cytokines: PHA, PMA + ionomycinFibronectin helps in uptake by phagocytic cells. • From www.latrobe.edu.au P. Reimers IBCLC

  9. Benefits of Donor Milk • Human milk is living tissue! • Faster emptying of stomach • Intestinal permeability is reduced faster • Less residuals and faster realization of full enteral feeds • Factors in breast milk stimulate gastrointestinal growth, mobility and maturation Wight, N. Journal of Perinatology 2001: 21:249-245 P. Reimers IBCLC

  10. Benefits (Cont.) • Improved cognitive & visual development (Uauy et al, 1990) • Less retinopathy of prematurity (Hylander et al, 1996) • Enzymes in b/m help immature infants absorb and utilize nutrients more efficiently (Hamosh,1994) • Immunological benefits • Protection against NEC • Appropriate lipid profiles (PUFA’s) • Considerable cost savings • Relieves infants pain and discomfort & parents anguish • Reinforces the importance of breast milk/breastfeeding P. Reimers IBCLC

  11. Necrotizing Enterocolitis • Lucas & Cole study( 1990)- Incidence was six-ten times more likely in infant fed formula exclusively than those fed breast milk exclusively • Bisquera (2002) Found that average length of stay for surgical cases was 60 days longer and cost $ 186,200 • Uni. of Leipzig use maternal and donor milk at one, two and three days post partum and have very low rates of NEC ( 0.2) Springer, 1997). • OstraSjukhuset in Gotsborg, Sweden. Infants are fed maternal or banked milk within the first 6-12 hrs of life. They start with 2-3 ml every three hrs slowly increasing until full enteral feeds at 5-6 days- only see one or two cases of NEC a year.( NICU 800-900 admissions a year) Arnold, 1999. P. Reimers IBCLC

  12. Financial Implications- Morbidity :MOM vs Pre-term Formula • Schlaner, Shulman, Lau. Pediatrics 1999 , 103(6):1150-1157 P. Reimers IBCLC

  13. Increased cost of NOT using breast milk in NICU P. Reimers IBCLC

  14. Clinical Uses • To supplement a mother’s own supply • For infants who are ill and have some medical condition • For cases where b/f is contra indicated HIV Pos mother/ chemotherapy • Preterm infants • Maternal death • Immune compromised babies & those orphaned due to HIV/AIDS • Adopted babies P. Reimers IBCLC

  15. Uses of Donor Milk -USA & Canada 2003 • Preventive Health Necrotizing enterocolitis AIDS Crohn’s disease Colitis P. Reimers IBCLC

  16. Uses of Banked Human Milk in 2003USA & Canada Medical and Therapeutic Short gut syndrome Infectious diseases Postsurgical healing Immunologic diseases Renal failure Inborn errors of metabolism Nutritional Prematurity Failure to thrive Malabsorption syndromes Feeding intolerance P. Reimers IBCLC

  17. Recipient Prioritization in allocation of Donor Milk • Prematurity • Malabsorption • Feeding intolerance • Immunological deficiencies • Congenital anomalies • Post-operative nutrition • Lactation failure • Adoption • Illness of mother • Health risk to infant from mother • Death of mothers P. Reimers IBCLC

  18. Donor Milk Fortification? • Composition of preterm milk ( 36 wks) & term milk differ • Debate on whether LBW & VLBW can achieve adequate growth on donor milk from term mothers • Can match gestationally appropriate milk to the recipient • Can use infra red analysis to determine fat, protein and carbohydrate content. In Scandinavia they do this and pool milk to meet the requirements of infants • Ultrasonic homogenization of EBM prevents fat adhering to feeding tubes, babies gained more weight( Marinez, 1989). Babies gained avg. 5 gm/day more • Current practice in Europe to add fortifiers to provide extra protein, calcium & phosphorus- drawbacks: contamination of powdered products, cows milk protein allergy, decreases amt of lysozyme and IgA esp. for E.coli P. Reimers IBCLC

  19. Fortification ( cont) • France they fractionate and freeze dry human milk and can fortify maternal or donor milk on an individual basis to bring protein content to 3.5g/kg Variations in protein & energy contents of human milk Schlaner, ABM, Oct, 1989, Adapted from Polberger 1996. P. Reimers IBCLC

  20. Donor Mothers • Health women who are breastfeeding their own babies • Screened to ensure meet requirements • Often have milk supply higher than the needs of their infant, or the supply can be stimulated by expressing • Mother of a deceased infant may also donate • Donors are not paid but are rewarded knowing they have helped someone • Donor are self-selected- hear about donating through child birth educator, baby magazines, hospital staff or word of mouth P. Reimers IBCLC

  21. Screening questionnaire • Have you received a blood transfusion or blood products in the last 12 months? • Do you regularly have more than 50ml of hard liquor or its equivalent in a 24-hour period? • Regular use of medications, or use of radio-active drugs or cytotoxins? • Are you a total vegetarian? • If yes, do you supplement your diet with B12 vitamins? • Do you use habit-forming drugs? • Do you smoke? • Have you ever had hepatitis B, HIV, or TB? • Have you ever had a sexual partner who is at risk for HIV, takes habit-forming drugs, or is a haemophiliac? • Do you have a copy of the results of your anti-natal HIV and syphilis tests? • If not, would you be prepared to undergo a rapid test for HIV at your expense and submit the results to the screening officer?  P. Reimers IBCLC

  22. Milk donation • Mother either express using a pump or hand expression • Given details about cleaning pump • Given storage bottles( glass best option) & each bottle is marked with the date of expression & donor number • Milk is frozen at -20 C and collected from the mother or dropped at a collection site • Milk is thawed and pasteurised at 62.5 C for 30 min • Cooled and frozen immediately • Microbiology- Titratable Acidity test post pasteurisation. Petrifilm for E. coli and coliform bacteria P. Reimers IBCLC

  23. P. Reimers IBCLC

  24. Cultural Acceptance of Donor Milk • Nigeria- 70% of mothers would not accept donor milk for their babies because of socio cultural reasons and religious beliefs (Ighogboja et al 1995). • Muslim women object to receiving milk from Hindu women • Jewish women may request milk from a mother following a Kosher diet • South African Mums? • Neonatologists and Paeds? P. Reimers IBCLC

  25. iThembaLethuBreastmilk Bank

  26. P. Reimers IBCLC

  27. Human Milk Banks in South Africa- KwaZulu Natal P. Reimers IBCLC

  28. Baby M P. Reimers IBCLC

  29. “Improvement was radical, dermatitis had resolved, gastroenteritis resolved, child was more alert and responsive, even the fisting had improved somewhat. This study was retrospective and there are poor records but if medical science can be considered both a science and an art, what breastmilk did for that baby is a masterpiece.” Dr SA Biliman & Dr Pather, Durban P. Reimers IBCLC

  30. Baby T • PCR positive, Mantoux positive • Arrived at IL 8 months • On breastmilk immediately • TB treatment from Oct 06-May 07 • Then started on HAART treatment • No repeated chest infections or diarrhoea- possibly due to the fact she has been on breastmilk for 14 months P. Reimers IBCLC

  31. Baby Pieter • Born at 28 weeks in W. Cape • Birth weight: 1 kg • Mother had previous breast surgery so was unable to provide breast milk for her baby • Couriered frozen breast milk down from iThemba Lethu • Discharged after 2 mths weighing 2.1kg. Had no respiratory or other infections P. Reimers IBCLC

  32. Baby S • Born 20/11/02, BW: 2.5 kg • Arrived at IL :29/1/03 • Weight: 3kg malnutrition, scabies, TB, respiratory distress and HIV pos. • Mother and grandmother had full blown AIDS. • Put on breastmilk. Gained weight despite respiratory infections and diarrhoea.He continued to receive the breast milk until he was 14 mths old. At 21 months he started on HAART treatment and has thrived. P. Reimers IBCLC

  33. King Edward Breast Milk Bank P. Reimers IBCLC

  34. Western Cape: Milk Matters Registered NPO and NGO Funding from UNICEF, Corporate, Public, Fuchs Foundation Charge for donor milk www.milkmatters.org Mowbray Maternity,* Tygerberg, *Groote Schuur Hospital, Panorama Mediclinic,* Wynberg Military Hospital, N 1 City Hospital, Chris Barnard Memorial Hospital, Kingsbury Hospital, Paarl Mediclinic Recruit Donors from: ANC Clinics, NICU’s, Pharmacies, Libraries, talks at maternity hospitals on radio, magazines, newspapers. P. Reimers IBCLC

  35. Mowbray Maternity P. Reimers IBCLC

  36. SABR- Gauteng • Pretoria Academic Hospital (PAH)NetcareParklane 'twinned' with BaragwanethNetcareFemina twinned with PAHN17 Springs twinned with Far East Rand HospitalNetcareCuyler twinned with Dora Ingiza Hospital and ProvincialHospital UitenhageUNIVERSITAS Bloemfontein supported by a number of privates in the areaSABR Head office Johannesurg supplies the excess to the other hospital facilities that use but don't bank activelySandtonMediclinic twinned with Kalafong P. Reimers IBCLC

  37. Redistribute DBM to over 20 hospital facilities in and around Gauteng. • o NetcareFeminao NetcareSunninghillo Netcare Garden City o NetcareClinton o NetcareParklane (Key donor) o Netcare Montana o NetcareCuyler o Netcare Pretoria East o NetcareUnitas o N17 Springs o Universitas Bloemfontein (our latest) o Pretoria Accademic o Kalafong (Key Recipient)o Wilgeheuwel o Eugene Maree o SandtonMediclinic (Key donor)o Clinics Soweto o Witbank Hospital (key recipient) o Medforum Pretoria P. Reimers IBCLC

  38. SABR- Gauteng P. Reimers IBCLC

  39. International Breast milk Project • Jill Youse in USA breastfeeding baby and had excess milk- contacted iThembaLethu early 2006 • Formed an NGO to send Breast milk to babies orphaned by HIV/AIDS • April 2006 contacted us again to send milk- first 2 boxes came with “courier” • Next shipment sponsored by DHL arrived in May 06 • ABC filmed and was shown on Oprah around the world • Further 5 shipments pasteurised and packed in individual bottles- stored in cold storage at Etlin P. Reimers IBCLC

  40. International Breastmilk Project P. Reimers IBCLC

  41. Current research regarding use of Donor Milk • Most bioactive properties remain viable after pasteurisation • Pasteurised donor milk for preterm and high risk infants reduces incidence of NEC, sepsis & infection resulting in shorter stays in hospital • Holder pasteurization reliably inactivates HIV and CMV and will eliminate titers of most other viruses( AAP,2000 & Lawrence,1999). P. Reimers IBCLC

  42. Storage of human milk and the influenceof procedures on immunological components of human milk. Lawrence RA. ActaPaediatr 1999.88:14-18 Summary: • Immunoprotective components of human milk are stable when stored at: -room temperature for 8hrs -0-4C for 3 days -frozen at -20 C for 12 mths • Stable after pasteurisation at 56 C x 30 min P. Reimers IBCLC

  43. Heat treatment of Breastmilk • Holder Method- 62.5 C for 30 min. P. Reimers IBCLC

  44. Holder Method- Brazil P. Reimers IBCLC

  45. HTST P. Reimers IBCLC

  46. Thawed Milk being poured into tanks P. Reimers IBCLC

  47. Filling bottles post pasteurisation P. Reimers IBCLC

  48. Pretoria Pasteurisation • Method uses passive transfer of heat from water heated to boiling point. • Place 50-150 ml breastmilk into clean covered glass jar. • Boil 450 ml water in small aluminum pot. Remove from heat –source. • Stand milk jar upright in pot of boiled water, cover the pot and leave for 15-20 min. • Maintains milk between 56˚C and 62.5˚C for between 12-15 min. • It effectively inactivates HIV in human milk % kills commensal & pathogenic bacteria (Jeffery et al J TropPeds 2001) P. Reimers IBCLC

  49. Flash Heating • Use I litre aluminum pot with 450 ml of water and a 450 ml glass jar with a lid. Place between 50-100ml of milk in the jar. • Place uncovered jar of milk into the pot of water and heat it over heat source. Water level should be two fingers above the level of the milk. • Once water boils, remove container of milk immediately from the pot and allow to cool P. Reimers IBCLC

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