The evidence is clear. Breastfeeding and human milk ensure the optimal development of infants. The American Congress of Obstetricians and Gynecologists, the American Academy of Family Physicians and the American Academy of Pediatrics all recommend a period of exclusive breastfeeding followed by complementary feeding with foods appropriate for a child’s age and development. Breastfeeding is associated with a reduced risk of ear infections, asthma, obesity, diabetes and other ailments.

But what if “normal” breastfeeding is not an option—as is the case for many very low birthweight (VLBW) preterm infants? Without proper nutrition, many of these preemies face the possibility of developing diseases, such as necrotizing enterocolitis (NEC) or potentially worse outcomes.

Experts from around the world gathered in Washington, D.C. recently to offer insights, review research and pull from their collective clinical experiences. Hot Topics in Neonatology served as the roundtable to advance the knowledge and care of vulnerable infants. It’s exciting to see the progress the field has made in expanding our knowledge of nutrition for preemies, and ways to improve breastfeeding practices and increase delivery of human milk.


Benefit of human donor milk

In many preemie cases, mothers are not able to provide the amount of milk these infants need for various reasons. Previously, these situations called for the use of formula, but recent developments have given us another option that utilizes human milk—donor milk banks.

Donor milk banks are a relatively new development with limited availability. Nemours Children’s Health System established a milk bank at Alfred I. duPont Hospital for Children in Delaware April 2015. Until now, data on the potential benefit of donor milk has been sparse, so researchers have turned their attention to this area. Researchers Deborah O’Connor, MD and Sharon Unger, MD, from the GTA DoMINO Feeding Group in Toronto, have begun adding to our knowledge base through their DoMINO (Donor Milk for Improved Neurodevelopmental Outcomes) trial.

In the DoMINO trial, O’Connor and Unger compared the growth, neurodevelopment, and rate of NEC in preterm infants receiving formula compared to those who received fortified, pasteurized donor milk. They note that fortification is important since the pasteurization process impacts the nutritional makeup of the donor human milk. While the DoMINO team found no differences in weight-for-age, length-for-age, head circumference-for-age, and neurodevelopment, they did find preemies who were fed donor milk had a lower rate of NEC compared to those receiving formula, which is an important benefit both for patient outcomes and reducing the cost of care.


Exclusively human breast milk is best

Milk banks pasteurize donor milk to ensure safety, but this process results in the loss of immunoglobulin A, lactoferrin, vitamin B6, and other milk components critical for infant development. In response to these deficiencies, clinicians supplement pasteurized donor milk with either bovine-derived fortifiers or human milk-derived fortifiers. Fortification also adds protein, calcium, phosphorous and zinc to the donor milk.

In exploring which fortification option resulted in better infant development, Amy B. Hair, MD, of Texas Children’s Hospital, and her team reviewed studies comparing the effectiveness of the bovine- and human-derived fortifiers. Not surprisingly, she found that a diet consisting exclusively of human milk resulted in lower mortality and morbidity, as well as a lower rate of NEC, compared to a diet with bovine-derived fortifiers. Additionally, she found that infants receiving a bovine-derived diet were eight times more likely to require surgery for NEC.

Using human milk-based fortifiers may be more expensive, at least on the surface, but a look at total costs may present a different picture. The cost of treating NEC is approximately $74,000 and, for NEC that requires surgery, that cost skyrockets to almost $200,000. Hair also points to data showing infants on an exclusively human milk-based diet had a shorter stay in the hospital, resulting in cost savings of more than $8,000.

At Nemours, we utilize both human and bovine-based fortifiers. We generally use human-based fortifiers for sicker infants who are most at risk for infections, and then transition to bovine-based fortifier later, as the infant is less at risk but still needs the added calories, vitamins, and minerals.


Steps to ensure breastfeeding

Many hospitals use recommendations outlined by the Baby-Friendly Hospital Initiative to promote breastfeeding in infants, but these recommendations do not address the specific needs of mothers with babies in the NICU. Diane Lynn Spatz, PhD, RN-BC, from the Children’s Hospital of Philadelphia (CHOP) developed the “Ten Steps for Promoting/Protecting Breastfeeding in the Vulnerable Infant” to address these needs and help promote extended breastfeeding for their children.

These steps include giving mothers the information to make an informed decision to breastfeed; establishing and maintaining a milk supply; ensuring correct breast milk storage and handling; feeding the infant breast milk; providing skin-to-skin contact; managing the transition to the breast; and providing appropriate follow-up care.

In adopting Spatz’s guidelines, Tampa General Hospital realized a three-fold increase in infants on human milk upon discharge and an increase in patient satisfaction. At Spatz’s CHOP, 86 percent of infants are discharged on human milk, compared to 44 percent of VLBW infants, according to the Vermont Oxford Network.


Mother’s Milk Continues to Be Best

Our NICU teams at AI duPont Hospital for Children treat more than 100 premature infants each year, so we are excited to see the increase in clinical data and practice guidelines. Mother’s milk is preferred but not always possible. It’s in these situations where our care teams of physicians, nurses, clinical nurse educators, and lactation consultants can reliably turn to our donor milk program for immediate needs and then utilize proven programs to support the ultimate goal of having mom breastfeed her baby.


  1. The more we learn about the benefits of breastfeeding, the more we need ways to help all babies start their lives with mother’s milk. This innovation in Donor Milk banking is a good addition to the list of support services for breastfeeding and mother’s milk. Thanks for the update.


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