Perspective Breast Milk, Janet Colson

PERSPECTIVE BREAST MILK JANET COLSON BREAST MILK THE PAST , PRESENT , AND FUTURE interest and experience in breastfeeding began during her work with the Supplemental Nutrition Program for Women Infants and Children ( in rural Mississippi . After five years of teaching new mothers how to feed their babies with , she transitioned to university teaching . Currently , she is a professor at Middle Tennessee State University , where she teaches life cycle nutrition classes . Learning Outcomes 420 BREAST MILK

After reading and discussing this text , students should be able to Trace the history of infant feeding practices over the last three centuries . Explain the importance of human milk for infant survival . Differentiate between , and . Identify the pros and cons of human milk . INTRODUCTION Shortly after my fathers birth in 1918 , his mother developed the Spanish , requiring her to be hospitalized for several weeks . During my grandmother absence , a neighbor cared for my father , who was less than a month old at the time . The neighbor fed him from her own breasts , a practice known as . A century later , the global COVID pandemic had a similar effect on newborns . Today , because is taboo in most tries , mothers too ill to nurse have the option to purchase another woman breast milk . Human milk is available to buy from accredited milk banks or from enterprising women selling their milk for extra income . Some lucky parents may have a friend or relative willing to supply breast milk free of charge , a practice known as milk sharing . According to public health , mothers unable to nurse should only use another woman milk that has been pasteurized , similar to the milk sold in This type milk is known as pasteurized human donor milk . How did we , as a global community , transition from a birth mother nursing from her own breasts , to outsourcing infant . 2020 JANET COLSON 421

feeding to paid wet nurses , to having a market for pasteurized human milk ?

We can trace the history to at least 1000 . MILK FOR HUMAN INFANTS Human breast milk has always been the gold standard for feeding infants . Humanity would not exist today had our ancestral ers refused to nurse . Perhaps one of the earliest Written records of nursing is found in Exodus from the Old Testament bible . The author describes how Moses mother hides him in a basket to prevent his execution and a princess finds the young infant and decides to adopt him . Realizing that he will need a wet nurse , Moses big sister tells the princess that her mother is willing to nurse the Not knowing that the woman is Moses actual birth mother , the princess pays her to serve as his wet nurse . Although not common , hiring a wet nurse is still an option for parents , but there are several other methods . As shown in Table I , the World Health Organization ( VVHO ) recommends human milk , fed directly from the natural mother breasts , as the best If an infant is too weak to nurse from the birth mothers breasts , the Woman should pump and feed her milk through a bottle or other feeding device . If the birth mother not produce enough milk to meet the needs of her infant , use of pasteurized human milk from an accredited donor milk bank ranks third . Fourth in this ranking is the use of a . Because it is not socially accepted in all cultures , WHO their stance may be an option depending on acceptability to mothers and families , availability of wet nurses , and services to support mothers and wet Commercial . Exodus . WHO 2021 . WHO 2021 . 422 BREAST MILK

infant formula is the least favorable method of infant feeding and should only be used if other methods are not feasible . Table The World Health Organizations hierarchy for infant feeding Rank Type of Milk and Feeding Method First Human milk fed directly from the birth mother breast Human milk pumped from the birth mother and fed through a bottle or other feeding device Second Third Pasteurized human milk from an accredited donor bank Fourth if acceptable to mother and family Last Commercial infant formula ( source World Health Organizations ) Most commercial formulas are made from cows and minerals added to make it resemble human from soy protein formulated in a similar way . In 1981 , after WHO concern about the global decrease in breastfeeding , the organization published the International Code of Marketing Their aim was to contribute to the provision of safe and adequate nutrition for infants , by the and promotion of , and by ensuring the proper use of substitutes , when these are The same year , the Codex established specifying the minimum content of 29 nutrients in infant The regulations have been updated several times to coincide with advances in research on nutrient needs of infants . The Codex requires that infant formula labels include a WHO 2021 . 1981 . 1981 . 2007 . JANET COLSON 423

ment describing the superiority of breastfeeding such as Breast milk is the best food for your INFANT FEEDING AND GROWTH DURING THE EARLY MONTHS Ideally , breast milk should be the only source of food given to infants for the first six months of life , with continued feeding as the baby begins eating cereals and other solid foods . The American Academy of Pediatrics ) recommends ing until age one and beyond , whereas WHO and the Canadian Pediatric Society both recommend continuation to two years of and beyond . Some mothers define beyond as five or six years , a practice criticized by mainstream parents , but acceptable to less traditional parents . Human milk has the perfect nutrient content for optimal infant growth . Table includes a few of the nutrients found in various mammalian milks . Human milk is much lower in protein and minerals than milk from other mammals , which is the ideal amount needed for a human baby growth pattern . Humans grow much more slowly than other mammals , gaining about one ounce per day in the first few months of life , whereas calves add an extra two to three pounds a day , topping out at 500 to 800 pounds by twelve months . A healthy human infant may weigh a mere or pounds by their first birthday . Table Comparison of nutrients in mammalian milks per 100 grams . 2007 . 10 . 2020 . WHO 2021 . 12 . Critch 2014 . 424 BREAST MILK

Nutrient Human Milk Cow Milk Goat Milk Buffalo Milk Energy ( 70 64 69 97 Protein ( Fat ( Carbohydrate ( Calcium ( 32 119 134 169 Phosphorus ( 14 93 11 I 117 Sodium ( 17 49 50 52 Vitamin ( source Food Data Central ) Background on Preterm Babies Weight and gestational age at birth the health status and survival rate of newborns . Infants born at or after 38 weeks of gestation are considered full term those born earlier are term . Birth weights vary by stage of gestation , as noted in Table Based on 2019 data , slightly less than two percent of infants are born at very low birth weight ( less than grams ) These very small frequently do not survive . Eight cent are low , weighing less than Those weighing at least grams are the healthiest , with few complications . Table Typical infant by gestational age of infants 13 . 2019 . 14 . Utah Dept . of Health 2021 15 . Martin 2021 . JANET COLSON 425

16 . 17 . Gestational age Category . Very low 1000 ( 28 ( 1500 ( Low 2000 ( 33 2500 ( 35 Average 3000 ( 38 ( term ) 3500 ( 40 3700 ( 42 ( Adapted from the Utah Department of Health Fetal Growth ) Until neonatal intensive care units ( became common in the , weighing grams or less had a very low chance of surviving . Today , necrotizing enterocolitis ( NEC ) is a intestinal condition occurring in about 10 of these very small infants . The condition , characterized by nal and perforations , often results in recognize that giving these babies infant formula worsens NEC survival is much greater if infants are fed human milk . However , many women who deliver prematurely are unable to produce an adequate amount of milk . Survival of these infants improves when given pasteurized human donor milk . NUTRITIONAL NEEDS OF YOUNG INFANTS Infants bodies are unable to digest and metabolize the high amounts of protein , calcium , phosphorus , and sodium in milk from cows and other large mammals . Commercial infant mula mimics the low protein and mineral content of human milk . Before the availability of commercial infant formula , infants given cow or goat milk developed severe diarrhea and Utah Dept . of Health 2021 . 2014 . 426 BREAST MILK

eventually died due the damage it caused in their immature ies . Today infants should not be given cow milk until at least age one because of this high protein and mineral content . A woman breast milk fulfills her own baby nutritional needs , not those of a baby who is older or younger than the child she birthed . Nutrients in breast milk vary by the age and needs of a womans biological child , not for the infant of a friend , family member , or complete stranger . Health of Human Milk In addition to the ideal balance of nutrients , human milk is often called liquid gold because of the numerous substances such as hormones , and it contains . In addition to the that are absorbed by the gastrointestinal tract , current research shows the high levels of contain properties that may decrease absorption of viruses and bacteria , thereby reducing Even though formula ers claim their products are closest to mothers milk by ing to replicate the nutrient and ingredients , they will never be able to replicate nature nutriment . METHODS OF FEEDING HUMAN MILK Although is rare in developed countries , the practice was common from prehistoric time until the early , when widespread use of infant formula became the norm . In fact , it was the only way to keep infants alive . Throughout history , wealthy families sent their newborns to live with a wet nurse until the child could drink from a cup and eat regular foods . Even poor 18 . Moore et . JANET COLSON 427

19 . 20 . families turned to wet nurses if the mother died at birth or was too ill to care for her own Hormonal changes that occur at the delivery of a newborn milk production in a womans breasts . Nutrients are est in milk produced for the first few months , when infants are growing rapidly , and decrease substantially after six months . Therefore , the ideal wet nurse is one who has recently given birth , when her milk is at its prime . During the and centuries , slave owners throughout the Americas often forced enslaved women who had recently given birth to nurse their wives newborns , instead of allowing the slaves to nurse their own infants . This practice often resulted in death of the enslaved infants , who were given cow milk or dirty water . 20 After abolition and slaves were set free , poor women took over as wet nurses for the wealthy . It became a , with doctors often helping wealthy new mothers hire a suitable wet nurse . Because a nursing woman needed to have recently given birth , the woman biological infant often suffered because she gave preference to the the paying infant , similar to the fate of enslaved infants . Today , nursing another woman infant is still practiced , although not broadly publicized . Mothers may join an informal nursing and nurse each others children , a practice known as . A quick internet search will show the top sites for promoting services , and also for buying and selling expressed milk . Only the and Breast Feeding Moms et al . 2016 . Slavery Facts 2019 . Only the Breast 2021 . 428 BREAST MILK

are two top sites . Of the postings on Only the Breast , 17 are for wet nurses . is term and practice that has emerged among people who choose to feed their babies from their chest , but who do not identify with the term breastfeeding for one of a number of reasons . Trans men who have undergone surgery to remove most of their breast tissue ( chest masculinization or top surgery ) as well as women who have have experienced related trauma often prefer this term . Similarly , a person may choose not to use the term breastfeeding , given the association it carries . If a trans man chooses to retain their uterus and ovaries , pregnancy is possible , and is often possible after delivery . Alternately , some trans women may want to feed an adopted baby , in which case mone therapy with nipple stimulation can make lactation ble . Breast Pumps and Expressed Milk Breast pumps have been around for about 200 years . The earliest ones consisted of a syringe connected to a glass These early pumps were painful and not efficient in suctioning milk , unlike the double electric pumps available today that work on both breasts simultaneously . See Figure . In the , the Patient Protection and Affordable Care Act of 2010 requires insurance companies to provide a pump for breastfeeding ents and specifies that employers allow time for women to pump during the The does not require employers to give paid maternity leave like most other developed countries , 22 . Breastfeeding Moms Unite 2021 . 23 . Bologna 2020 . 24 . et al . 2017 . JANET COLSON 429

resulting in many women returning to work a few weeks after birth . Providing a pump encourages continued breastfeeding throughout the first year . Figure A double electric pump speeds the time needed to collect milk for working mothers or for women who choose to donate or sell their excess milk . photo Commons . 430 BREAST MILK

Women vary in their milk production , with some able to pump an additional 20 to 30 ounces each day after feeding their own babies . Entrepreneurial mothers may choose to sell their surplus milk to other parents as a source of income . Based on Only the Breast postings , most women charge between US and US per ounce , with vegan milk priced slightly A few altruistic mothers freely give their excess milk , representing a huge savings to parents in need . One problem with pumping and storing milk is that it loses some nutritional value . Small amounts of nutrients cling to the tube and collection container while pumping . Pouring milk into a plastic bag to freeze , and from there into a bottle for feeding , results in additional nutrient loss . An infant nursing directly from their mothers own breast thus provides the highest quality nutriment . THE PRACTICE OF Research has also been done on the experience of Representing both milk recipients and milk donors , mothers from various continents shared their opinions about the bonds formed with the donor or recipient , health aspects of ing milk , and opinions of other family members . As they noted In Islamic culture , we have to maintain the relationship because me giving my milk to another baby has created a familial bond meaning that my children and my milk children can not marry one Donor It gives you kind of a lifelong connection . It hard to explain but I look at my sons milk siblings with Donor 25 . Only the Breast 2021 . 26 . Gribble 2018 . JANET COLSON 431

For so long I was very cynical about life and other ple , but being able to be involved in the modern It takes a whole village to raise a baby idea has changed my of what is going on in our Recipient My son gained 10 pounds in months after we started receiving donor milk . He did not gain any weight his first month of life . He is healthy and Recipient I think the only negative repercussions were from my family who are not keen on breastfeeding . I got weird looks and disgusted Recipient UNPASTEURIZED HUMAN MILK Health care experts frown on individuals selling or giving breast milk because it is unpasteurized . Researchers at Ohio State the microbial content of breast milk bought online . They found bacterial contamination in 75 of the samples , poor collection , storage , or shipping Pasteurization would have destroyed the bacteria , making it safe for babies . In another study , the same researchers bought 102 human milk samples a shocking ten percent contained cow Parents buy human milk assuming it is 100 percent human milk , devoid of cows milk or other additives . Infants who have a milk allergy may suffer a reaction when given the adulterated milk . Some parents may also be tempted to water down their milk to increase profit , resulting in inadequate nutrients and calories . While pasteurization protects against pathogenic microbes , it has its downside . The high heat processing destroys many of the substances and vitamin content . In a review of 44 27 . et al . 2015 . 28 . et al . 2014 . 432 BREAST MILK

ies that examined the nutrient and content of human , results showed that the , enzymes , and vitamin levels were much lower in the pasteurized product than in the fresh milk . However , most other nutrients were HUMAN MILK BANKS Human milk banks are services that accept , pasteurize , and bottle donated breast milk and provide it to the frail babies in hospital . The first American milk bank opened in the early in Boston , after physicians realized that very small infants failed to thrive if given the cows milk formula common at the time . The word spread and human milk banking grew steadily in North America . By the , Canada had 23 milk banks and the had 30 . However , the crisis in the resulted in closure in all but one in Canada and the vast majority in the In 1985 , the Human Milk Banking Association of North America ( organized and now nonprofit milk banks in Canada and the . The Association developed international guidelines for pasteurized human donor milk . Canada has four milk banks and the has 25 , with eral applying for Milk banks face several . In addition to health crises ( such as the COVID pandemic effect of decreasing donations ) their operating cost is high . They must pay to screen the mothers , test for purity and bacterial els in the milk , then pasteurize , bottle , package , store , and ship the final product . As a result , the banks must charge US to US per ounce for the pasteurized human milk to cover 29 . et . 30 . Hayward 2018 . 31 . Human Milk Bank . 2021 . JANET COLSON 433

their A tiny preterm infant may drink only one ounce per feeding , but as they grows , the amount increases to 20 to 30 ounces per day . Although North American efforts are better than most other countries , Brazil is considered the global leader in donor milk banks With a history of the practice dating back to the , the country also has a three public health law that stipulates all the steps required to operate a human donor bank , based on advice from scientists at the respected research organization , Today , Brazil has 217 milk banks , plus another 126 milk collection points , with at least one bank in each of the country 26 to Sao Paulo . Last year , Brazilian women donated breast milk an even larger number of infants reaped the benefits . This huge system is centrally organized every state has a reference bank An online portal called , which has won praise from foreigners , facilitates a vast data lection operation , and enables the public , as well as the , to stay informed . the national reference bank is information via a newsletter , conducts research , and runs undergraduate and graduate programs on policy and applied for milk Human Milk for In contrast to the endeavors described above , two companies buy human milk , process it into human milk 32 . Human Milk Bank . 2021 . 33 . 2015 . 434 BREAST MILK

, then sell if for a profit . Both were founded by Elena . Her first was , which began in 1999 and sold its first 100 human milk products to hospitals in 2006 . The company pays women US per ounce for their milk , processes it into a variety of 100 human milk forms , and sells it to hospital around the In 2009 , left to form a new that follows a similar The Future of Human Milk The future of commercial ventures for human milk appears to be endless . In 2020 , two visionary entrepreneurs introduced mary biotechnology at their North . Their company is developing a process to grow human milk in the lab . The process will include collecting a womans mammary cells the cells in a lab collecting the milk made by these cells and shipping the milk to hungry Their current research focuses on the protein and content of human milk . It will be easy to add the needed vitamins and minerals following the Codex infant formula standards . However , the seemingly unlimited variety of substances provided in the liquid gold secreted from a womans real breasts will be more complex , if not impossible , to replicate . Will the public accept this substance as a new form of human breast milk , or will they consider it an artificial ?

Will the WHO add this type milk to their hierarchy for infant feeding ?

Will this milk be superior to commercial infant formula or just another expensive alternative ?

Only time will tell . 34 . 2021 . 35 . 2021 . 36 . 2021 . JANET COLSON 435 CONCLUSION Human milk is the sustenance that has allowed civilization to continue it is considered the gold standard for feeding babies . Originally , infants received the substance directly from breasts of the . Today , natural secretion serves as a source of income for some parents and a profitable venture for private industry . It is well known that processing and milk results in losses of many of the beneficial substances in human milk , yet pasteurization is recommended by all health organizations . infants , at high risk of life threatening NEC , depend on the pasteurized human donor milk for survival . a practical profession and a major source of income for women in the past , has become taboo ( or secretive ) in many developed cultures . Is or sharing any different ?

Would society be healthier if wet nurses became a new and recognized profession or should we wait until biotechnology allows growing human milk in a lab to replace human breasts ?

Although , the future of infant feeding holds many uncertainties , the one universal truth is , infants must be fed to survive . Discussion Questions Breastfeeding mothers of today often produce more milk than is needed to feed one infant , resulting in a surplus of stored milk . Describe three ways a mother with excess expressed breast milk can use the milk , and the protocol she needs to follow in handling the milk . Tiny Treasures Milk Bank is 436 BREAST MILK

route for women to donate ( at US 31 per ounce ) expressed breast milk . Using their Frequently Asked Questions , answer the following a What are the steps a parent must take to donate milk to Tiny Treasures ?

a In you were lactating and had a surplus of milk , would you consider donating to Tiny Treasures or to your local milk bank ?

Explain your sion . In the early , commercial infant formula in China was found to be adulterated with melamine , resulting in several infant deaths . New working mothers resorted to hiring wet nurses to feed their infants . Image that you were one of these working mothers looking for someone to your infant . Write a posting for the internet , specifying your requirements and the salary you would pay to the wet nurse . You adopt a newborn and are told about ways to induce lactation through the use of hormones . Because you work full time , you decide against it . You still want your baby to have the best nutrition possible . Discuss the pros and cons of feeding your infant by the following methods a commercial infant formula asking a friend who is lactating a to give you breast milk a buying breast milk from a stranger on the JANET COLSON 437

internet a buying pasteurized 100 human milk from a hiring a wet nurse Breastfeeding and paid paternity laws vary by country . Select two countries and compare their laws to those of your own country . Explain the food system associated with human milk that is being prepared to be sold to a hospital neonatal care unit . References Breastfeeding Moms Accessed February 20 , a Only the Accessed February 20 , 2021 . and Cohen . 2016 . From Royal Wet Nurses to The Evolution of Breast Milk Breastfeeding Review Professional Publication of the Nursing Mothers Association 24 ( 2021 . Unlocking Human Potential with Breakthrough Mammary Human Milk for Babies . Accessed May 10 , 2021 . 438 BREAST MILK

Bologna , 2020 . 200 Years of Breast Pumps In 18 Post . 30 . Centers for Disease Control and Prevention . 2020 . ing Frequently Asked Reviewed May 28 , 2020 . Critch , 2014 . Canadian Pediatric Society . Nutrition and Gastroenterology Committee . Nutrition for Healthy Term Infants , Six to 24 Months An Paediatrics Child Health 19 ( 10 ) Exodus Food and Agriculture Organization of the United Nations , World Health Organization . 2007 . Standard for Infant Formula and Formulas for Special Medical Purposes Intended for Adopted 1981 , Amended 1983 , 1985 , 1987 , 2011 , 2015 , 2016 , and 2020 . Revised 2007 . Gribble , 2018 . Someone generosity has formed a bond between us Interpersonal relationships in milk Maternal child nutrition 14 ( Human Milk Bank Association of North America . 2021 . Accessed February 20 , 2021 . and . 2017 Lactation Support Services and Breastfeeding Initiation Evidence from the Affordable Care Health Services Research A ( Hogan , Dillon , and . 2013 . Microbial contamination of human milk purchased via the Pediatrics 132 ( JANET COLSON 439

, Kulkarni , Hogan , and . 2015 Cow Milk Contamination of Human Milk Purchased Via the Pediatrics 135 ( Martin , 2021 . Births Final Data for National vital reports from the Centers for Disease Control and Prevention , National Center for Health Statistics , National Vital Statistics System 70 ( 2021 . Human Based Milk for A Public Benefit Corporation . Accessed May 10 , 2021 . Moore , Xu , and Townsend . 2021 . Prospecting Human Milk as a Defense against Viral Infectious Diseases ( and Hayward . 2018 . Medicine , Body Fluid and Food The Regulation of Human Donor Milk in care policy de 13 ( Moro , and . The Effect of Holder on Nutrients and Components in Donor Human Milk A Nutrients ( A . 2015 . Milk Banks Around the . 2021 . Leader in Human science . Accessed February 22 , 2021 . and McGuire . 2014 . Formula versus donor breast milk for feeding preterm or low birth weight The Database of Systematic Reviews . 440 BREAST MILK

Slavery Facts . 2019 . Breastfeeding Masters Babies The Nurse United States Department of Agriculture . 2019 . Agriculture Research Service . Food Data April , 2019 . Utah Dept . of Health . 2021 . Fetal Growth Accessed 20 , 2021 World Health Organization . 1981 . International Code of of January 28 , 1981 . World Health Organization . 2021 . Clinical Management of Accessed May 10 , 2021 . JANET COLSON 441