Wednesday, December 1, 2010

Who should get donor milk? Who should it be offered to?

Dou-la-la's post on encouraging the informed milk use of donor milk over formula supplementation got me thinking. At the hospital where I work, I have a lot of parents ask me about supplementation. They want to do los dos from the beginning, or they believe that the mother's colostrum isn't sufficient, or they're concerned that the fussy baby who wants to nurse constantly is starving, or they're tired of the fussy baby nursing constantly and just want to sleep. If they're really set on it, I encourage them to supplement at the breast vs. with a bottle, and not to give too much. If they're considering it but haven't decided yet, I do my best to educate them about risks of supplementation, including compromising future milk supply and altering the baby's gut. But in the end, it's their baby and their choice if they want to supplement.

Sometimes, I have to tell parents - even parents who don't particularly want to hear it - that we need to supplement. Because their baby has lost too much weight, or because there are latch difficulties, or because there is persistent hypoglycemia not helped by just direct breastfeeding. We do our best to supplement with only the mom's own expressed milk, but sometimes we have trouble getting enough of it out. In the end, those parents have to supplement - it's a medical necessity.

The thing is, no one at our hospital actually has to supplement with formula. We have banked, pasteurized human milk available for our NICU babies, and the term babies can access it as well if the parent requests it and gets a physician order. We don't need to ration it; the milk bank will tell us if they're running low and will ration appropriately on their own. We can offer it to anyone we want and they can use as much as they need while they're in the hospital, with the cost covered completely by the hospital, regardless of their insurance (or lack thereof). But once they go home, they have to purchase it from the milk bank directly themselves (unless they can convince their insurance provider to reimburse) or they have to find donor milk through other, less formal channels (as Dou-la-la discusses).

The other day one the nurses made an observation to me about who she usually sees using donor milk and who she doesn't. She asked if we offered it to everybody or if there was some discrimination going on. It got me thinking about it, and I talked to one of the other LCs about who gets offered donor milk and who should get offered donor milk. We had fairly similar feelings about it, but I won't say right now what we thought. I would like to ask all of you.

Since there's now a fairly active blogosphere conversation about donor milk being the ideal supplement for babies who are not being fully breastfed by their mothers for whatever reason: Who should be offered donor milk when the decision to supplement arises - for personal or medical reasons - and who should not? Why?


Arual said...

Everyone should be offered donor milk if they would otherwise look to formula, regardless of if their baby is premature or full term, if they're a stay-at-home-mom struggling with supply or a working mom struggling with supply... Donor milk should be the very first option considered for supplementation, period.

Christie B. said...

I've been hoping to read a bunch of comments on this post because it was very thought-provoking for me. I can't say that I have a perfectly formed, logically consistent position on this, but I have a hard time thinking that donor milk should be provided for free to women who are not trying their best to provide their own milk (if not contraindicated) for their own babies. If there is a medical issue, it makes sense for donor milk to be covered like a pharmaceutical but otherwise donor milk seems like a luxury good/service, like eating out instead of cooking.
I'd definitely be interested in hearing some other perspectives since I feel like I'm being a bit kneejerk here.

Rebecca said...

Christie, I'm also hoping I get more comments! I really am very curious to see what people think. Please pass it along if you think other people would be interested in discussing.

Sara Rosen said...

As a first year MPH student studying Maternal and Child Health, I've only begun to learn about the intricacies of breastfeeding vs. formula. While I completely agree that breastfeeding is superior to formula (and that formula should be outlawed!), I don't think that every woman should be offered donor milk. For those women who have their hearts set on breastfeeding but have medical conditions (physiological, disease, etc) and cannot, these women should definitely be offered the donor milk. We all know - either from experience or friends - that breastfeeding is difficult. The option of offering donor milk to everyone would both deplete the supplies and give women an out. Not to mention the health benefits that are transmitted between mother and child through breastmilk. Overall, increased education about breastmilk and breastfeeding - exclusive for 6 months - are the key to making sure that women use their breastmilk, when possible, to nourish their babies.

Anonymous said...

How plentiful is the donor milk? At first I thought every baby who would otherwise have formula should have access to it - human milk for human babies.

But upon reflection (and realizing that the supply of donor milk is obviously not infinite), I believe that donor milk should be offered when the mother has the intent to breastfeed and needs to supplement (unless it is medically indicated that she shouldn't breastfeed).

Thank you so much for your blog! I'm interested in birth and breastfeeding and considering an MPH, so your blog is a treasure trove. :)


Jespren said...

I had a baby in the NICU and, after a querry to a nurse after seeing a very ill baby getting formula (they were very pro bf and went out of their way to help when I was aving supply issues so it seemed odd) I was told that many NICU moms, due to separation and stress, lose their milk and are unable to keep pumping. So I feel that 1st dibs on donated breastmilk should go to NICU babies whose mothers have supply issues or have dried up and are unable to produce milk. Next I think it should be offered to mothers of healthy babies who can't physically produce any/enough milk. (This would include adopted babies whose new moms can't lactate) finally, if there is still milk availible, it should be offered to babies whose mothers chose not to breastfeed. While my kneejerk reaction is, these mothers should just bf if they want their babes to have breastmilk but, truthfully, even if the mother just 'didnt feel like it' it still doesn't make sense to penalize the babies. But, for moms that have no physical reason not to breastfeed, they should have to purchase it, preferable at the same cost as formula. (I don't understand for a moment why DONATED breastmilk is so prohibitively expensive once it goes through a 'milk bank')
Of course I think it would be a lot easier if we could just get rid of the stigma around wetnursing and make formula availible through prescription only.

Molly (First the Egg) said...

I've been pondering your post and its questions, and I don't have any answers--largely because I have never been and will never be in the position of making any of these decisions. Two points do occur to me, though:

1) The post's title asks two 'to whom' questions: "Who should get donor milk? Who should it be offered to?" In considering these questions, we should probably ask what 'whom's we mean: postpartum women, babies, families? You can't exactly offer a medical option to a baby, so in the second case presumably we mean the baby's parents (why only mothers, as some responses seem to suggest?). In the first question, the implication seems again to be that parents/mothers are the ones getting the milk: does it make any difference if we reconceptualize the question to mean, explicitly, 'which babies deserve access to donor milk (rather than formula)?'

2) How does class privilege play out here? Education, internet access, reading literacy, technological literacy, financial ability to purchase (and leisure time to read) books, access to high-quality mother-centered prenatal care, etc., etc.? If anyone can ASK for donor milk, should my baby get human milk simply because I'm an overeducated overprivileged English-speaking birth junkie who knows to ask the secret right question? Or, if limits on offering ought to be imposed (according to some standard of need or worth or whatever), is there any way to counteract that injustice?

Burrowing In said...

As a mother whose baby was blessed by donor milk, I want to say that every baby should have access to it if necessary. Forget the mothers and their intentions and their shortcomings and their socioeconomic status. BABIES deserve that milk! Of course, there will be parents out there with no intention of breastfeeding, and lots of parents in addition who will have qualms with breastmilk...especially donated breastmilk from strangers (nevermind their ignorance, please).

I had my son and life began to unravel in tragic ways, as life sometimes does. I lost 2 people who were so, so dear to me just days apart in unrelated circumstances. I was grief-stricken and my milk supply took a hit. My son already had trouble accessing all the milk, which we were working on, but when my supply dwindled he lost weight rapidly. He was 7 weeks old and lost 2 pounds in 3 days. He was admitted to the hospital. I was doing EVERYTHING under the sun to boost my supply and help solve his sucking issues. Domperidone, all the herbs, pumping, nursing, rock unturned. Donor milk saved my son's life! I know formula would have done the same thing, but it meant so much to me that he get the breastmilk. Every baby deserves that if it is possible for him/her to get it!