Post on 05-Aug-2020
The Provincial Authority for The Breastfeeding Committee for Canada
Informal Milk Sharing:Do we have our heads in the sand?
“Milk sharing has deep social (and some might argue biologi-cal roots). It’s not going to just go away because health authorities caution against it. It is part of our past, our present, and most likely our future. What is happening on-line is just scratching the surface”. (Aunchalee Palmquist, Anthrolactology, 2014)
bc baby-friendly network
1.What are families saying?• “I’vecriedafewtimeswhileexplaininghowgratefulmyfamilyandIarefortheirkindness.Ithascompletelyupliftedmyviewofhumanitytoseeallthesestrangersapproachmewithsuchwarmth,givingthegiftoflifetomybabyoutofasenseofloveandthedesiretohelp,withoutaskingforcompensationinreturn.”(Nese)
• “Sinceshestartedchemotherapy,she’sgottensomanydonationsofmilk,wefoundafreezerforstorage,andafewofushavebeentakingturnsnursingherbabytokeepherusedtothebreastwhilehermamaundergoestreatment.”(Heather)
• “Inhisfirst22monthsoflife,myyoungestsonwasnourishedwithbreastmilkfromabout30women,myselfincluded.Ihaveinsufficientglandulartissue(IGT)anddon’tproducemuchmilk.Itriedeverything,includingmedicationandherbs,tostimulatemilkproductionbutnothingworked.”(Allison)
• “Weweresomethingofanovelty:agaycoupleseekingbreastmilkonMilkshare…Itisdifficulttoexpressenoughgratitudeforsuchagiftthatisgivensograciouslyandatnocharge.”(Dr.TafadzwaKasambira,M.D.,M.P.H.)
Why do women and families informally milk share?Intheabsenceofmother'sownmilk,ormilkinadequatevolumes,andwithoutaccesstopasteurizeddonormilkfroma regulatedmilkbank,therearefamilieswhochosetoprovideinformallysharedmilktotheirinfantratherthangivingthebabyahumanmilksubstitute.
3. What has been our official response?It is not the role of the health care provider to promote informal milk sharing. Health Canada (2014), the Canadian Paediatric Society (2014), and the Human Milk Bank Association of North America (HMBANA, 2015) do not endorse the use of unpasteurized donor human milk.
What has been our unofficial response ... don’t ask, don’t tell?
5. Guiding Principles:Any discussion on the risks of informal milk sharing
musttakeplacewithinthelargercontextof
therisksandbenefitsofallinfant
feedingoptions.Throughout
childhood,parentsmakedecisions
regarding the nutrition of their
child.Thesedecisionsmaybe
influencedbytheirbeliefs,values,
andsocialcircumstances.The
rightofparentstomake
informed decisions regarding
the care of their children is
respectedwithinthecontext
of Canadian law
(QueensPrinter,2014).
4. Is all human milk created equal?
ProjectTeam:LaniWittmann,KnowledgeTranslationCoordinator,PerinatalServicesBC;MeggieRoss,PublicHealthMaternityProgram,InteriorHealth;LeaGeiger,LactationConsultant,RoyalInlandHospital;FrancesJones,CoordinatorB.C.Women’sProvincialMilkBankandLactationService,BCWomen’sHospital;SwatiScott,Dietitian,PublicHealth,IslandHealth
Nursing Lucia with a supplemental nursing system filled with donor milk. (Photo Credit: Aunchalee Palmquist, PhD, IBCLC, www.anthrolactology.com)
Assumption of Escalation of Risk: Thismodelisbasedonanumberofassumptions.Itispossiblefortheretobeindividualsituationsofhigherorlowerriskanywhereonthescale;forexample,adonorfamilymembermaybeunawareofa+HepCstatusorfailtodisclosetheiruseofdrugs.
Comparison of Risk between Pasteurized Donor Human Milk and Unpasteurized Donor Human MilkProcess PDHM UDHM
Donor Screening ClearlysetstandardsbyHMBANA Nostandards,informal,andsubjective
Donor’s Serology Tests RequiredlistofserologicaltestssetbyHMBANA Maybeavailableuponrequest,maynotinclude correct lab tests or current status
Treatment Pasteurizedinaregulatedandcontrolledenvironment which Maybetreated.Difficulttoensurecontrolledincludes,temperaturecontrols/containers/refrigeration/etc. environmentfortemperature/container/etc.
Handling and Shipment StandardizedbasedonsetguidelinesbyHMBANA Difficulttoensureconsistenthandling
Post Treatment Milk Screening TestedperguidelinessetbyHMBANA Nottested
(HMBANA, 2014)
Mother’s ownmilk
Pasteurized donor human milk from a regulated milk bank
Unpasteurized donor human milk from family or friend
Unpasteurized donor human milk from community/ face-2-face (unpaid)
Unpasteurized donor human milk from internet (unpaid)
Unpasteurized donor human milk from internet (paid)
Increasing Unknown Risk
Lowest Risk?
Highest Risk?
Where do your values and beliefs lie?
8.The Tool Kit: Resources Developed for Health Care Providers 9. What’s Next?Knowledge Translation
1. ApracticeresourceguideforHCPs
2. Infantsupplementationoptionsalgorithm
3. Scriptforhealthcareproviders
4. Samplepolicyontheuseofunpasteurizeddonorhumanmilk
5. Acknowledgment of Risk form
6. PatientInformationSheet-HealthLinkBC
Infant Supplementation Options AlgorithmBaby requires supplementation • Medical Indications • Maternal Informed Decision
OPTI
ONS
RESO
URCE
S
Human Milk Substitute(Commercial formula)l Not the biological norm4 Readily available and
accepted, considered safe8 Risks: Non-human;
inferior composition, costs, short and long term health risks (e.g. impaired cognitive development, ↑gastrointestinal and re-spiratory tract infections, ↑otitis media, ↑obesity)
Donor Milk - Human Milk Bankl The next best and safest
choice. Pasteurized.4 Benefits of human milk;
rigorous donor/milk screen-ing, Holder pasteurization and milk handling prevents transmission of pathogens and other substances (e.g. nicotine, alcohol, herbal supplements, medications, street drugs)
8 Limited availability
Mother’s Own Expressed Milkl Always the first choice4 The biological norm8 No risks (unless mother’s
milk contraindicated)
l Healthy Families BC: Hand Expression and Pumping Videos
l Baby’s Best Chance
l Donor Human Milk Policy
l BC Women’s Provincial Milk Bank Patient Information
l Consent for Infant Supplementation Form
l Infant Formulas for Healthy Term Infants Compendium
l HealthLinkBC Formula Health Files 69a & 69b: Formula Feeding Your Baby
l Consent for Infant Supplementation Form
l Donor Human Milk Policy
l Informal Milk Sharing: A practice resource for HCPs
l Supplementation with un-pasteurized donor human milk - Script for the HCP
l Informal Milk Sharing Patient Information
l Informal Milk Sharing: Acknowledgement of Risk Form
Donor Milk - Informal Milk Sharing
l Not endorsed by Health Canada or the Canadian Pediatric Society.
4 Benefits of human milk8 Risks: No standard or
reliable donor/milk screening, pasteurization or handling process; ↑risk for transmission of patho-gens and other substances
So far we have engaged in the process of knowledge inquiry, synthesis and tool creation. The Knowledge to Action Cycle provides a framework for toolkit implementation.
Identity problem
Sustainknowledge
use
Evaluateoutcomes
Monitorknowledge
use
Select, tailor, implement
interventions
Assess barriers to knowledge
use
Adapt knowledge to local context
Knowledge Inquiry
Tailo
ring
know
ledg
e
KNOWLEDGE CREATION
Identity, review,select knowledge
ACTION CYCLE(Application)
Synthesis
ProductsTools
Contact email – psbc@phsa.ca
Purpose: A Perinatal Services BC/BC Baby-Friendly Network working group was formed to develop a practice resource tool kit for health care providers on the use of unpasteurized donor human milk, based on the principles of patient-centered care, informed shared decision making, and harm reduction.
2. Who is filling the gap?Breastfeedingispromotedwithouttheneededprotectionandsupport,leavingsomefamiliessearchingformilkfortheirbabies.Pasteurizeddonor humanmilkfromaregulatedmilkbankisnotyetreadilyavailabletomanybabies.Informalmilksharingisfillingthisgap. Informalsharingofhumanmilkisnotanewphenomenon.Throughouthistoryandacrosscultures,milksharing(wet-nursing,cross-nursing,co-nursing, milkdonations)hasbeenusedbyfamiliesasastrategyforinfantfeedingwhenamotherorhermilkwasunavailableorunsuitable.Thepractice,however, enteredthe21stcenturywiththeadventofsocialnetworkingsitesthatareabletoconnectmotherswithoneanother(Thorley,2008).
Just like breasts, milk sharing organizations come in all shapes and sizes.Therearemilksharingorganizationsthatfacilitatefreepeer-to-peersharingofmilkwhosemembersaremotivatedbyaltruisticvalues,andothersthatarebasedonthesaleofdonormilkwithprofitforthedonorand/ortheorganization.
“In an era when the benefits of breast milk are better understood and more scientifically certain than ever, demand for it has created a niche industry.” (Dutton, 2011 www.wired.com)
Eats on Feets:16,616followersinternationally•HM4HB:60,127followersontheglobalpage
Worl
d Milk Sharing Week
Autonomy
Respect
Values
Parental rights
Patient rights
Human rights
Canadian law
Evidence-informed care
Collaboration
Full list of references available on request • April 2015
6. Informed Consent:• Who decides what are ‘reasonable’ alternatives?• Whose values and beliefs prevail?
FORMULA FORMULAINFORMAL SHARED MILK
INFORMAL SHARED MILK
Milk Sharing: Survey of Health care Providers –
Please scan this QR code to participate in our survey,
and to leave us your contact information if you are
interested in receiving the Resource Toolkit when it
becomes available.
(Graham, 2006)
“Basically,it’sa‘don’task,don’ttell’situation,right?SometimesIhavewonderedifamomisbringinginhersister’smilkorsomethinglikethat,butIhaveneverfeltcomfortableraisingthediscussionbecausequitefrankly,Idon’tknowwhatIwouldsay.ImightthinkitisOK,butIdon’tknowifIcanlethergiveitorhowtoadvise her–orhowtochartit!”(NICU Nurse – BC)
“IhavehadmothersinthebreastfeedingclinicwhohavetoldmetheyareusingdonatedmilkoffaFacebookpage.Idon’tknowifourhealthauthorityhasa guidancedocumentaboutthisthisorwhatmyroleshouldbe.Mostofusare awarethisishappeningbutsofarwehaven’taddressedit.Wereallyneed somedirectiononthis.”(PHN, BC)
“TheCanadianPaediatricSocietysaysmilkthatisn’tfromamilkbankshouldn’tbegiventoababy,it’stoounsafeifitisn’tpasteurized–soifamothereveraskedme,IguessIwouldhavetosay‘don’tdoit’.ButnoonehaseveraskedmesoIdon’tthinkthishappensveryoften.”(Family Physician, BC)
7. Milk Sharing Mind Map
Any discussion on the risks of informal milk sharing must take place within the larger context of the risks and
benefits of all infant feeding options.
Governing Principles: recognizing that breast milk and breastfeeding is
the preferred food for infants
Governing Principles: recognizing that breast milk and breastfeeding is the
preferred food for infants
In order to make an informed decision on infant feeding, parents must be aware of all the options. Health care providers need knowledge, skill and
support around delivering risk and benefit messages regarding infant feeding. (OPHA, 2007)
Supplementation with UDHM - Script for the Health Care Provider: The script gives an example of the type of conversation a HCP
might have with parents who have indicated a desire to use UDHM as the method of supplementation for their infant.
Sample Policy • UDHM
HCP Engagement Survey
Acknowledgement of Risk form
Infant Supplementation Options Algorithm: Summarizes risks and benefits of all
supplementation options with links to matching resources
These principles guide the HCP when engaging in a discussion with parents
about their infant feeding choices.
Informal Breast Milk Sharing: a patient handout for parents summarizing the risks and perceived benefits of the use of
UDHM, and harm reduction strategies, including donor screening, flash heating, and the safe collection, storage and
handling of human milk. Parents should be encouraged to take some time to consider their options, learn more, and ask
questions before they decide.
In the context of UDHM, any strategies that aim to reduce the potential negative health
consequences of informal milk sharing would be considered in keeping with harm
reduction principles.
While it is not the role of the HCP to promote informal milk sharing, if parents raise this option for consideration,
the HCP must be able to discuss with the parents evidence-based information on the risks and benefits.
Informal Milk SharingGUIDING
PRINCIPLES OF PATIENT CENTRED
CARE, SHARED INFORMATION
DECISION MAKING, AND HARM REDUCTION
Health Canada, the Canadian Paediatric Society, and the Human Milk Bank Association of North America do not endorse the use of UPDHM.
Getting Started: Sept 2014
BFI Step 6: support mothers to exclusively BF, unless
medically indicated
Collaboration: Working Group developed and representation from PSBC & BCBFN
Goals: To Meet Population and Patient Health Needs
Process
INFORMED DECISION
SHARED INFORMED DECISION
The following decision tools, HCP, and parent information resources have been developed to support this process
PATIENT CENTRED CARE
FAMILY RESOURCESHARM REDUCTION
BACKGROUND
Milk Sharing Work Group: Opening a Can of Worms?
http://fluidsurveys.com/surveys/psbcfluidsurveys/informal-milk-sharing/