Australian College of Midwives Draft Position Statement on the use
of Donor Human Milk
Consultation Paper: 17 January 2014
The Australian College of Midwives (ACM) is currently developing a Position
Statement on the Use of Donor Human Milk. The Draft provided below has been
developed by the Baby Friendly Health Initiative (BFHI) Advisory Committee based
on available evidence.
To ensure the final endorsed Position Statement is informed by the latest evidence
and expertise and reflects professional and regulatory codes, standards and
frameworks, we now ask for feedback from members and interested stakeholders on
the draft provided below.
Unless provided in-confidence, submissions will be published on the ACM website
after the public consultation period, to encourage discussion and inform
stakeholders and the broader community.
Once the consultation period ends, the feedback will be collated to inform a final
draft. This will then be reviewed by the BFHI Advisory Committee and submitted for
endorsement by the ACM Board. The final Position Statement will then be published
on the ACM website (http://www.midwives.org.au).
HOW TO SUBMIT
Once completed, there are three ways to make your submission;
1. Online survey: https://www.surveymonkey.com/s/8ZZFKH7
2. Email: sarah.stewart@midwives.org.au
3. Post:
Sarah Stewart
Australian College of Midwives
PO Box 965
Civic Square ACT 2608
For those who prefer to email or post their responses, we encourage you to:
1
1. Download the position statement (doc and pdf) and utilise the questions
included as a guide for your feedback.
2. Include any additional comments you may have.
3. Include the following as the title for your submission: Consultation – Use of
Donor Human Milk.
4. Provide your name, job title and, if representing an organization, the
organisation’s details.
Unless provided in-confidence, submissions will be published on the ACM website
after the public consultation period, to encourage discussion and inform
stakeholders and the broader community.
There is no need to send a hard copy of your submission if you have submitted it by
email. The ACM endeavours to formally acknowledge receipt of submissions within 5
business days.
DEADLINE FOR SUBMISSIONS: COB Friday 28th February.
Submissions received after this date will not be considered.
Any questions about this consultation process may also be directed to Sarah
Stewart:
Email: sarah.stewart@midwives.org.au
Phone: 02 6230 7333
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ACM Position Statement on the use of Donor Human Milk
The ACM supports and encourages parents to exclusively breastfeed their children to six months,
with continued breastfeeding to 12 months and beyond as recommended by the NHMRC Infant
Feeding Guidelines: Information for Health Workers (2012). The ACM believes parents should be
fully informed of the options to achieve this goal, one being the use of Donor Human Milk. The
benefits and risks of this option are well documented; health professionals and parents need to be
aware of these when making an informed decision on how they feed their infant.
Key principles

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



The benefits of exclusive breastfeeding are well researched and documented. Parents are
increasingly looking for ways to optimise the start to life that exclusive breastfeeding can
afford their infant.
The World Health Organisation noted that “for those few health situations where infants
cannot, or should not, be breastfed, the choice of the best alternative – expressed breast
milk from an infant’s own mother, breast milk from a healthy wet-nurse or a human-milk
bank or a breast-milk substitute… depends on individual circumstances.” (WHO, 2003)
When situations occur when a mother’s own breastmilk is unavailable or insufficient to fully
nourish her infant then use of donor human milk could be considered.
Historically all infants were mother or wet-nurse fed. Human milk sharing occurred in
Australian maternity hospitals up until the 1980s when fears re HIV and CMV stopped this
practice. It re-emerged in 2006 with the first formal human milk bank in Perth, WA. There
are currently both community based and hospital based donor human milk banks in
Australia.
In many cultures women routinely share their milk and the breastfeeding of infants in their
community. Internet-based milk sharing models are emerging and families using this
unregulated service need to be well informed about potential risks to make this a safe
choice.
In the increasingly complex biological milieu of today’s society, health professionals need to
ensure it is medically and ethically safe to recommend the use of donor human milk and that
the viral and bacterial transmission risks are assessed and mitigated before recommending
or proceeding with its use.
Do you think the title: 'Position Statement on the Use of Human Donor Milk' is appropriate? If not,
why not?
Do you think the Background information provided in the Draft Position Statement is adequate? If
not, why not?
If you have any suggested changes to the Background of the Draft Position Statement, please
describe.
Do you agree with the key principles as outlined in the Draft Position Statement? If not, why not?
If you have any suggested changes to the Key Principles as outlined in the Draft Position Statement,
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please describe.
Ensuring Best Practice in a Health Care Setting
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
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Donors need to be carefully screened for health concerns and potential infections that can
be transmitted via breastmilk. This process is the same as that which occurs in a blood bank.
Additionally, questions are asked related to the donor’s health and that of her infant; any
medical treatments, tests, prescribed and non prescription (complementary) medications
being taken; herbal supplements; recent infections; environmental and chemical
contaminant exposure; cigarette use or exposure and alcohol consumption. (NICE, 2010).
During formal screening, assessment of the potential donor’s milk supply also occurs to
ensure her own baby is thriving and that surplus breast milk is available to donate.
International recommendations for Donor Human Milk Banks is to screen potential donors
for HIV 1 and 2 antibody; Human T cell Lymphotrophic Virus I and II antibody; Hepatitis B
surface antigen and Hepatitis B core antibody; Hepatitis C antibody and Syphilis antibody .
Commercial Holder pasteurisation (heating to 62.5o C for 30 minutes) of the breastmilk
ensures bacteria removal and virus inactivation. If this option is not available then the
addition of Cytomegalovirus to the screening blood tests is recommended (Hartmann, 2007).
Un-pasteurised breastmilk should contain less than 105 Colony Forming Units (CFU)/ml of
total viable microorganisms, or less than 104 CFU/ml S Aureus or less than 104CFU/ml
Enterobacteriaceae and no growth after pasteurisation (NICE, 2010) . In some Australian
Donor Milk Banks, breastmilk is not used if it contains any Staph Aureus pre-pasteurisation.
Donors require education on best practice for hygienic collection, labelling, storage and
transporting of their breastmilk.
Staff handling donated breastmilk should follow established procedures to ensure correct
handling and storage occurs. A tracking and tracing protocol must be implemented.
In the absence of a Human Milk Bank being available, it may be acceptable, feasible and cost
effective to consider donors known to the mother for the provision of breastmilk. Utilise all
the above mentioned precautions and testing, and ensure informed decision-making by the
recipient mother and the donor occurs. Confidentiality of information and test results are a
significant additional consideration.
Do you agree with the considerations for Achieving Best Practice as outlined in the Draft
Position Statement? If not, why not?
If you have any suggested changes to the considerations for Achieving Best Practice in the
Draft Position Statement, please describe.
4
Community Considerations





The decision amongst friends and family to share the provision of breastmilk to an infant,
either by direct feeding or via expressed breastmilk is a very personal one. As a health
professional, awareness of this practice amongst clients indicates a need for careful scrutiny
to ensure informed decision making by the client and others occurred.
The manner in which a community donor collects and stores breastmilk for donation is very
important. Information on best practice is necessary to minimise risks.
Families accessing donor milk in the community need to ensure the breastmilk is
transported and stored correctly and consumed within accepted timeframes. (NHMRC,
2012.)
Knowledge of how to access Human Milk Banks, if in the local area, will assist any clients
who may need this service. Currently, milk banks located within hospitals do not provide
pasteurised donor milk for babies in the community.
There is access to free and costed breastmilk sharing via commercial and non commercial
sites on the internet. Caution is needed to ensure safety and honesty for both sides of this
transaction.
Do you think any changes to the Resources to Guide Practice are required? If so, what changes?
Resources and References to guide practice
Statement kindly reviewed by Kerri McEgan and Gillian Opie of Mercy Health Breastmilk Bank.
Akre et al, 2011, ‘Milk sharing: from private practice to public pursuit’, International Breastfeeding
Journal, 6:8.
Gribble, K, 2012, ‘Biomedical Ethics and Peer-to-Peer Milk Sharing’, Clinical Lactation.
http://media.clinicallactation.org/3-3/CL3-3gribble.pdf
Hartmann, B et al 2007, ‘Best practice guidelines for the operation of a donor human milk bank in
an Australian NICU’, Early Human Development, 83, pp 667-673.
McGuire, E 2007, ‘Vertical transmission of viruses via breastmilk’, in Hot Topics, No 25, Lactation
Resource Centre, Australian Breastfeeding Association.
NHMRC,
2012,
Infant
Feeding
Guidelines:
Information
for
Health
Workers,
http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/n56_infant_feeding_gui
delines.pdf
5
National Institute for Health and Clinical Excellence (NICE), 2010, Donor breast milk banks: the
operation of donor milk bank services (NICE clinical guideline 93), there is also a Quick Reference
Guide available. www.nice.org.uk/cg93.
Smith, J, 2013, ‘''Lost Milk?': Counting the Economic Value of Breast Milk in Gross Domestic Product’,
Journal of Human Lactation, http://www.ncbi.nlm.nih.gov/pubmed/23855027.
Smith JP and Harvey PJ, "Chronic disease and infant nutrition: Is it significant to public health?",
Public Health Nutrition, Vol.14 No.2, February 2011, pp.279-89.
World Health Organisation/ UNICEF, 2003, Global Strategy for Infant and Young Child Feeding.
Australian College of Midwives Draft Position Statement on the use
of Donor Human Milk.
Background
The benefits of exclusive breastfeeding are well researched and documented.
Parents are increasingly looking for ways to optimise the start to life that exclusive
breastfeeding can afford their infant. The ACM believes parents should be fully
informed of the options to achieve this goal, one being the use of Donor Human Milk
(DHM). The benefits and risks of DHM are well documented; health professionals and
parents need to be aware of these when making an informed decision on how they
feed their infant. Historically all infants were mother or wet-nurse fed. Human milk
sharing occurred in Australian maternity hospitals until the 1980s when fears around
HIV and CMV stopped the practice. Formal milk sharing re-emerged in 2006 with the
first dedicated DHM bank opening in Perth, WA. There are currently both
community based and hospital based DHM banks in Australia. In many cultures
women informally share their milk and the breastfeeding of infants within their local
community. Internet-based milk sharing models are also emerging. These are
unregulated services. Families using these services need to be well informed about
potential risks to make this a safe choice.
The ACM identifies four key principles to ensure the safe and appropriate use of
donor human milk in Australia.
Key principles
1. The ACM supports and encourages parents to exclusively breastfeed their
children to six months, with continued breastfeeding to 12 months and
beyond as recommended by the NHMRC Infant Feeding Guidelines:
Information for Health Workers (2012).
6
2. The ACM endorses the World Health Organization’s position that the decision
to use human milk from the mother, healthy wet-nurse or human milk bank in
preference to a breastmilk substitute be made depending on individual
circumstances (WHO, 2003). In the event of a mother’s own breastmilk being
unavailable or insufficient to fully nourish her infant then donor human milk
should be considered.
3. The ACM supports the formation of formal donor human milk banks in
Australia and reiterates the need to follow accessible, feasible, affordable,
safe and sustainable provision of breast milk to babies.
4. In the increasingly complex biological milieu of today’s society, health
professionals need to ensure it is medically and ethically safe to recommend
the use of donor human milk and that the viral and bacterial transmission risks
are assessed and mitigated before recommending or proceeding with its use.
Achieving best practice
Considerations around achieving best practice in provision of DHM in health service
facilities include:



Donors need to be carefully screened for health concerns and potential
infections that can be transmitted via breastmilk. This process is the same as
that which occurs in a blood bank. Additionally, questions are asked related
to the donor’s health and that of her infant; any medical treatments, tests,
prescribed and non-prescription (complementary) medications being taken;
herbal supplements; recent infections; environmental and chemical
contaminant exposure; cigarette use or exposure and alcohol consumption.
(NICE, 2010). During formal screening, assessment of the potential donor’s milk
supply also occurs to ensure her own baby is thriving and that surplus breast
milk is available to donate.
International recommendations for Donor Human Milk Banks is to screen
potential donors for HIV 1 and 2 antibody; Human T cell Lymphotrophic Virus I
and II antibody; Hepatitis B surface antigen and Hepatitis B core antibody;
Hepatitis C antibody and Syphilis antibody. Commercial Holder pasteurisation
(heating to 62.5o C for 30 minutes) of the breastmilk ensures bacteria removal
and virus inactivation. If this option is not available then the addition of
Cytomegalovirus to the screening blood tests is recommended (Hartmann,
2007).
Un-pasteurised breastmilk should contain less than 105 Colony Forming Units
(CFU)/ml of total viable microorganisms, or less than 104 CFU/ml S Aureus or
less than 104CFU/ml Enterobacteriaceae and no growth after pasteurisation
(NICE, 2010) . In some Australian Donor Milk Banks, breastmilk is not used if it
contains any Staph Aureus pre-pasteurisation.
7



Donors require education on best practice for hygienic collection, labelling,
storage and transporting of their breastmilk.
Staff handling donated breastmilk should follow established procedures to
ensure correct handling and storage occurs. A tracking and tracing protocol
must be implemented.
In the absence of a Human Milk Bank being available, it may be acceptable,
feasible and cost effective to consider donors known to the mother for the
provision of breastmilk. Utilise all the above mentioned precautions and
testing, and ensure informed decision-making by the recipient mother and
the donor occurs. Confidentiality of information and test results are a
significant additional consideration.
Further best practice considerations in community settings include:





The decision amongst friends and family to share the provision of breastmilk to
an infant, either by direct feeding or via expressed breastmilk is a very
personal one. As a health professional, awareness of this practice amongst
clients indicates a need for careful scrutiny to ensure informed decision
making by the client and others occurred.
The manner in which a community donor collects and stores breastmilk for
donation is very important. Information on best practice is necessary to
minimise risks.
Families accessing donor milk in the community need to ensure the breastmilk
is transported and stored correctly and consumed within accepted
timeframes. (NHMRC, 2012.)
Knowledge of how to access Human Milk Banks, if in the local area, will assist
any clients who may need this service. Currently, milk banks located within
hospitals do not provide pasteurised donor milk for babies in the community.
Breastmilk is able to be purchased on the Internet through commercial and
non-commercial sites. The lack of a governing regulatory body to monitor
quality means caution is needed to ensure safety and honesty exists.
Midwives should advise mothers to exercise caution and to perform a
thorough investigation of the supplier to ensure the transparency of the
transaction and safety of the product prior to finalising any negotiation.
Resources to guide practice
 Akre, J Gribble, K & Minchin, M 2011, ‘Milk sharing: from private practice to
public pursuit’, International Breastfeeding Journal, 6:8.

Gribble, K 2012, ‘Biomedical Ethics and Peer-to-Peer Milk Sharing’, Clinical
Lactation,
Available
from:
http://media.clinicallactation.org/3-3/CL33gribble.pdf
8

Hartmann, B, Pang, W, Keil, A, Hartman, P & Simmer K 2007, ‘Best practice
guidelines for the operation of a donor human milk bank in an Australian
NICU’, Early Human Development, vol. 83 no. 10, pp: 667-73.

McGuire, E 2007, ‘Vertical transmission of viruses via breastmilk.’ Hot Topics,
No 25, Lactation Resource Centre, Australian Breastfeeding Association.

NHMRC 2012, ‘Infant Feeding Guidelines: Information for Health Workers’.
Available
from:
http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/n56_infant
_feeding_guidelines.pdf

National Institute for Health and Clinical Excellence (NICE) 2010, ‘Donor breast
milk banks: the operation of donor milk bank services (NICE clinical guideline
93)’, there is also a Quick Reference Guide available. Available from:
www.nice.org.uk/cg93.

Smith, J 2013, ‘''Lost Milk?” Counting the Economic Value of Breast Milk in
Gross Domestic Product’, Journal of Human Lactation, published online 12
July; 29 pp.537-46.

Smith, J & Harvey PJ 2011, ‘Chronic disease and infant nutrition: Is it significant
to public health?’ Public Health Nutrition, vol.14 no.2, pp.279-89.

World Health & United Nations Children’s Emergency Fund 2003, ‘Global
Strategy for Infant and Young Child Feeding’. Available from:
http://www.who.int.org
9