Statements on breastfeeding & human milk.

Various groups and organisations from around the world have released public statements about breastfeeding and human milk. Selected paragraphs from some of them are reproduced here because they refer to premature infants, necrotizing enterocolitis and make recommendations on alternatives when a mother’s own milk is not available. Click on the title to see the full statement.

National Coalition for Infant Health (NCfIH),
March 2018

The National Coalition for Infant Health (NCfIH) – applauds the development of nutritional guidelines for preterm infants by the American Academy of Pediatrics (AAP Section on Breastfeeding), the National Perinatal Association (NPA) and the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN). Evidence-based guidelines must be constructed in a manner that reflects the overwhelming body of evidence to establish exclusive human milk for very low birthweight babies as our nation’s standard of care.

For preterm infants born at less than 1,250 grams, the evidence for the use of an exclusively human milk diet devoid of foreign protein is conclusive.

Moreover, the definition of an exclusive human milk diet is exactly that: mom’s milk and/or screened and pasteurized human donor milk plus a human milk-based fortifier.

These studies demonstrate:
1.Significant reductions in the incidence of all NEC and in the risk of surgical NEC

Global Breastfeeding Collective
(PATH, UNICEF,World Health Organisation),
November 2017

Enhanced policies and programs are needed to effectively protect, promote, and support breastfeeding. This includes focus on sick and vulnerable newborns who are at greatest risk of negative health outcomes in the absence of human milk, such as those born preterm or low birthweight.

In these special cases when the optimal choice of direct breastfeeding is not a possibility, the World Health Organization (WHO) recommends the use of donor human milk, not formula, as the next best option for ensuring exclusive human milk feeding until mother’s own milk becomes readily available via breastfeeding or milk expression. Further, WHO recommends that if donor human milk is needed, then it should be safely provided through a human milk bank (HMB).

While donor human milk cannot provide the full benefits of direct breastfeeding from a newborn’s mother, it is preferable to infant formula due to reduced risk of sepsis, necrotizing enterocolitis, diarrhea, and feeding intolerance, as well as length of stay in critical care.

American Academy of Pediatrics,

December 2016

A new policy statement from the American Academy of Pediatrics (AAP) supports using donor human milk to help boost the health of small, preterm babies when needed, but calls for screening, pasteurization and distribution through established donor milk banks to ensure safety.

Human milk offers advantages for all newborns, but particularly benefits infants weighing less than 1,500 grams (about 3.5 pounds), according to the AAP. Studies show infants fed human milk have lower rates of necrotizing enterocolitis, for example, a life-threatening intestinal disorder that primarily affects premature babies.

Consensus Development Conference, EXPO 2015,
May 2015

The Panel members agree on the statements from the American Academy of Pediatrics and the ESPGHAN Committee on Nutrition which state that because of the potential benefits all preterm infants should receive HM [human milk]. OMM [own mother’s milk] should be the primary diet, and if OMM is not available or not in sufficient quantity, pasteurized donor human milk obtained from a recognized HMB [human milk bank] should be used.

The advantages of HM include protection against NEC and sepsis, and its trophic effects on the gastrointestinal tract.

American Academy of Pediatrics,
March 2012

Necrotizing Enterocolitis

Meta-analyses of 4 randomized clinical trials performed over the period 1983 to 2005 support the conclusion that feeding preterm infants human milk is associated with a significant reduction (58%) in the incidence of necrotizing enterocolitis (NEC). A more recent study of preterm infants fed an exclusive human milk diet compared with those fed human milk supplemented with cow-milk-based infant formula products noted a 77% reduction in NEC.19 One case of NEC could be prevented if 10 infants received an exclusive human milk diet, and 1 case of NEC requiring surgery or resulting in death could be prevented if 8 infants received an exclusive human milk diet.

Preterm Infants

There are several significant short- and long-term beneficial effects of feeding preterm infants human milk. Lower rates of sepsis and NEC indicate that human milk contributes to the development of the preterm infant’s immature host defense. The benefits of feeding human milk to preterm infants are realized not only in the NICU but also in the fewer hospital readmissions for illness in the year after NICU discharge. Furthermore, the implications for a reduction in incidence of NEC include not only lower mortality rates but also lower long-term growth failure and neurodevelopmental disabilities. Clinical feeding tolerance is improved, and the attainment of full enteral feeding is hastened by a diet of human milk.

The potent benefits of human milk are such that all preterm infants should receive human milk. Mother’s own milk, fresh or frozen, should be the primary diet, and it should be fortified appropriately for the infant born weighing less than 1.5 kg. If mother’s own milk is unavailable despite significant lactation support, pasteurized donor milk should be used. Quality control of pasteurized donor milk is important and should be monitored.

Canadian Paediatric Society,
November 2010 (reaffirmed Feb 2016)

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. There is a limited supply of donor breast milk in Canada and it should be prioritized to sick, hospitalized neonates who are the most vulnerable and most likely to benefit from exclusive human milk feeding.

Nevertheless, it has been shown that human breast milk-fed infants in the neonatal intensive care unit (NICU) have fewer severe infections, less necrotizing enterocolitis (NEC) and a reduction in colonization by pathogenic organisms.

A systematic review comparing donor breast milk with infant formula has recently been published. There were only eight studies that met the criteria for inclusion in the Cochrane review, and only one study compared nutrient-fortified breast milk. There was a reduction in NEC in donor breast milk-fed neonates. The authors concluded, however, that further research was required because most studies did not follow current feeding practices, which may account for the slower growth that was seen in donor breast milk-fed babies. The use of exclusive human breast milk intake that included the mother’s breast milk and/or donor human breast milk plus a novel human-based human milk fortifier has been shown to reduce NEC by 63% and surgical NEC by 92% compared with an intake of the mother’s milk and a standard bovine fortifier in extremely preterm infants weighing less than 1250 g.

Royal College of Paediatrics & Child Health,
August 2017

RCPCH strongly supports breastfeeding, the promotion of breastfeeding, the provision of advice and support for women, and national policies, practices, and legislation that are conducive to breastfeeding.

All paediatricians should be aware of the RCPCH position on breastfeeding and encourage and support mothers, including those with preterm or sick infants, to breastfeed. They should avoid undermining breastfeeding through the inappropriate use of infant formula “top-ups”, and advise women that the use of infant formula may make it more difficult to establish exclusive breastfeeding.

Royal College of Paediatrics & Child Health,
January 2018

Pasteurised human donor milk is not the same as expressed milk from a baby’s own mother. There is an insufficient evidence base to recommend pasteurised human donor milk over formula for preterm and full-term babies in modern neonatal care when maternal breast milk is insufficient or unavailable.