An ethical dilemma: should recommending antenatal expressing and storing of colostrum continue?

Forster et al (2009) contend that the practice of recommending antenatal expressing and storing of colostrum by mothers with Type 1 diabetes should cease until its efficacy can be tested in a randomised controlled trial (RCT). This contention raises an ethical dilemma. To undertake a RCT, researchers would require a control group of mothers who would not be educated about how to express and store their colostrum. The hypoglycaemic infants of these mothers would need to be given artificial milk based on cow’s milk, with all its proven risks. An additional ethical consideration would be that midwives and other health professionals would need to decide whether or not to continue a practice that has not been proven harmful, but has immunological benefits to neonates. In considering whether antenatal expression and storing of colostrum by pregnant Type 1 diabetic women should continue, a number of criteria need to be assessed including: the original reason for implementing the procedure; the immunological value of colostrum in preventing autoimmunity and Type 1 diabetes in the offspring; the differences in milk that women produce during pregnancy compared to colostrum; the importance of an extra glucose source for babies of hyperinsulinaemic mothers; the likelihood of nipple stimulation inducing labour; and the question of whether the women find the procedure a positive experience. The practice of harvesting colostrum was instituted so that hypoglycaemic infants of insulin-dependent diabetic mothers would not receive cow’s milk formula in the place of colostrum as their first nutrition after birth. A number of studies have demonstrated that receiving oral fluids other than colostrum at birth carries potential life-long health risks (Borch-Johnsen et al 1984; Mayer et al 1988; Glatthaar et al 1988; Virtanen et al 1991; Cavallo 1996). Cavallo (1996) and co-workers hypothesised that early exposure to cow’s milk protein triggered the gut immune system to the later development of beta-cell autoimmunity, a cellular and humoral anti-beta casein immune response that crossreacted with a beta-cell antigen in the pancreas leading to cellular damage in the pancreas and Type 1 diabetes. On reviewing these studies, Vaarala (2000) suggested that, for the prevention of Type 1 diabetes, infants with a genetic risk of diabetes should avoid treatment that will interfere with mucosal immunity, such as the early introduction of cows’ milk (CM) formula. Colostrum is known to be the vitally important first food for all mammalian offspring. As Hanson states in Immunobiology of Human Milk: