Donor Milk Banking in
South Africa
Prof Anna Coutsoudis
Dept Paediatrics &
Child Health, UKZN
What is Human Milk Banking (HMB)?
A system that - collects, screens, pasteurises
and dispenses human milk donated by
breastfeeding mothers for infants who for a
variety of reasons do not have access to their
own mother’s milk.
It gives the message that breastmilk is so
important for infants that when it is not
available we put systems in place to access
this valuable commodity.
Why Donor Milk for vulnerable infants?
• Mother’s own milk is best option for babies
• Where this is not possible the FIRST
alternative according to WHO and UNICEF is
the use of donor human milk for:
– Orphaned infants
– Low birth weight infants – who do not
have access to mother’s own breastmilk
– These infants are particularly vulnerable
to necrotising enterocolitis if fed on
formula milk, therefore donor milk is
vital for them where mother’s own milk
is not available
Many developed countries responded to
this need by opening donor breastmilk
banks
However Brazil has led the world in the
breastmilk banking ………
The Brazilian National Network of HMB
• The largest HMB system in the world
– 200 banks supplying milk to 170,000 infants (per year)
• Supported by Ministry of Health
– Integral part of the strategy of promoting breastfeeding
– Government-led social marketing campaigns and
education in schools/health centers helped to raise the
visibility of human milk banking
– Attributed donor breastmilk to lowering of Brazil’s IMR
by >50% between 1980-2009
– Saved approximately $540 million in one year
The Brazilian National Network of HMB
Systems in place
- Convenient drop-off stations
- Fire fighters/policemen collect
milk from donors weekly
- Commercial –grade machines
that automate the Holder
pasteurization method
- Milk is tested for fat, acidity,
protein, calcium
Procedures are supervised from
municipality/state levels
History of Milk Banks in South Africa
• HMB once existed informally in neonatal units
– Donated breast milk
– Wet-nursing
• 1980s HMBs stopped as HIV discovered in breastmilk
• Later heat treatment was proven to render milk safe,
while preserving most of its immune properties thus
milk banks started operating again in US and UK
• In 2000 the first community based HMB was started in
Durban, KwaZulu-Natal specifically to provide
breastmilk for AIDS orphans
First Community Based Breastmilk BankiThemba Lethu
Baby A
• Was born prematurely
weighing 1500g
• Abandoned in hospital.
He was brought to the
home at 7 months of
age weighing 2700g. In
7 months of being fed
on formula he put on
1200g!
• In 2 weeks of
being fed on
donated breastmilk
he put on 550g
The success of this bank resulted in many
other banks being set up in South Africa
• Established HMB
–24+ banks in seven provinces
• (GP, KZN, WC, FS, EC, MP and NC)
• Recipient facilities
–10+ (public and private -majority in
Gauteng)
• Drop off corners
–Approx. 4, mainly in KZN
Apart from the community HMB all other HMBs
are attached to neonatal intensive care units
1. The public model – public hospital staff run
the milk bank but operations funded by
donations/grants
• Several hospitals in W Cape serviced by Milk Matters
• Kalafong Hospital & King Edward Hospital
2. The public-private partnership model
• South African Breast milk Reserve (SABR)
The Public Hospital Model
• HMB is situated within neonatal
unit
• Pasteurization of milk by:
– Commercial pasteuriser
– One hospital Kind Edward Hospital
in Durban uses
low-technology pasteurization
system – flash-heating
Jar of milk is flash heated - once the water is rapidly boiling.
the jar of milk is removed
• Donors
– Donors are recruited within
the hospital, screened for lifestyle risks, and screened for
HIV
– Dedicated area for mothers
to express milk –where
possible, mothers are
matched: preterm milk given
to preterm babies
• Recipients are infants who
– Do not have access to mother’s breastmilk
– weigh < 1500 grams
– HIV exposed infants prioritized
– Provided by prescription from a doctor
• Up to 14 days
• Depending on availability of milk and the infant’s
health
The Public-Private partnership modelrun by SABR
• Donor milk is processed and stored at a central
point usually in the private hospital (fees levied)
– supply milk to > 40 Hospitals
• Recipients in private hospital - are asked to donate
money to support operations of the HMBprocessing and transporting charges
• Recipients in Public hospitals -receive donor milk
for free/or minimal administrative fee
Human Milk Banking Association of South
Africa (HMBASA) www.hmbasa.org.za
• Non-profit organization whose objectives are to
coordinate, advise, and monitor HMBs to ensure
adherence to their guidelines.
• Board of HMBASA consists of wide spectrum of
professionals (eg obstetricians, neonatologists,
microbiologist, lactation consultants)
• Database of milk banks in SA isnavailable on website
Underlying principles:
• HMBs should go hand in hand with the promotion,
protection and support of breastfeeding.
• Milk banks should operate on a non- profit basis
Increasing Acceptability of
Donor Breast Milk
What are the concerns about donor milk?
2009 acceptability study using focus group discussions in Durban, KZN:
• Fear
– Possible transmission of HIV and other diseases
– Stored breast milk-even if refrigerated-unsafe after several hours
• Lack of awareness on procedures for
– Screening of donors for infectious diseases
– Cold storage
– Pasteurization to render breastmilk safe
• Cultural issues
–
–
–
–
Sense of discomfort with donated milk
Religious prohibitions against sharing breast milk/ bodily fluids.
infants may take on the genetic traits of the milk donor.
Donor’s race was not a significant issue.
What were main concerns about donor milk?
Discussants felt that hygiene and safety were
much more important than factors related to
race and ethnicity in determining
acceptability.
A lack of familiarity with the processing of donor
breast milk—including donor screening,
pasteurization, and cold storage—is the largest
impediment to greater acceptability. This can be
readily remedied, however, through education.
How can acceptability issues be
overcome?
• Knowledge about processes
and standards can address
lingering concerns
• the more women donate, the
more infants will benefit, and
the more acceptable the
practice will become.
Ensuring safety and
quality of Donor Breast
Milk
Screening of Donors to reduce risks
• Good health and no high-risk lifestyle behaviours
• Tested for HIV, syphilis, hepatitis B, infectious
diseases.
• If donating for > 3 months, HIV test is repeated.
• No piercings, tattooing, traditional scarification
and blood transfusion in past 12 months .
• Non-smokers/drugs
• No hard liquor
• No intake of medications which are contra-indicated
while breastfeeding.
Ensuring safe handling in donors’ homes
• Donors must follow rigorous safety measures for
handling and storing breast milk at home.
• Training on hygiene and expressing breast milk
• Use of glass jars or hard plastic containers supplied
and donor number given
• Donors must have working freezers for immediately
freezing milk after it is expressed
• Frozen milk must be transported in secure cool
boxes packed with ice packs.
Processing and pasteurization
•Donor breast milk must be kept frozen
until pasteurized (as soon as possible
after collection)
•Processed under hygienic conditionshand-washing/sterile gloves.
•Pasteurization
•Holder method-commercial-grade
pasteurizer -62.5 C/ 30 min
•Flash-heating- higher temperature (72 C)
for shorter time (heating milk-filled glass
jar in a bath of boiling water).
Safe-guarding Quality at the Milk Bank
• Post-pasteurization procedures
–Sterile technique is maintained throughout
processing
–Confidential records are kept for 5 years
–Donor breast milk samples are labelled with
• donor number and date of collection
• pasteurization batch number and date.
Safe-guarding Quality at the Milk Bank
Post-pasteurization procedures
•samples are tested
regularly for bacterial
contamination
•Donor pasteurized milk
stored at –18°C for up to 6
months
•Pre-term infants, breast
milk stored for only 3
months.
Safe-guarding Quality at the Milk Bank
Trained staff for optimal results
HMB are managed by trained
personnel-medical director,
neonatologists, lactation
consultants, and
microbiologists
On-going training should
cover SOPs, checking of
equipment etc.
Saving lives and Resources
wider use of donor milk to vulnerable infants
promises to cut costs while reducing lifethreatening complications
Saving lives and Resources
Feeding breast milk to lbw
infants lowers the
incidence of:
• Septicemia
• Necrotizing enterocolitis
(NEC)
• Neurological impairment
• malabsorption
Saving lives and Resources
US study – calculated that for each $1 spent on donor
milk to prevent NEC they would save $37 in hospital costs
for treating NEC
Wight N, J Perinatology 2001
• What would the cost-savings be in South Africa if
HMB was integrated into the health care system?
– To date, this has not been fully investigated.
Comprehensive cost-effectiveness studies of HMB are
needed to fully demonstrate the potential benefits of
this strategy.
Conclusion
• HMBs in South Africa are successful but limited
access.
• Expanding HMB could benefit vulnerable infants
and improve child survival
• HMB could be integrated into national
breastfeeding promotion strategies.
• Knowledge about processes and standards may
address lingering concerns
• Quality assurance standards must be maintained
while scaling up availability of HMBs.
Conclusion
Dept of Health leadership and support are vital to
ensure HMBs are given credibility amongst the
community. This will allow scale up and regulation
of milk banking to ensure safety and adherence to
guidelines of human milk banking.
Rough estimate that money (204 million) spent on
formula in the PMTCT programme could fund many
thousand breastfeeding counsellors who can also
be used to oversee donor breastmilk banking
activities in neonatal units (as an integrated
breastfeeding promotion strategy).