Contemporary Ethical Issues in Human Milk-Banking in the United States

Donor human milk has been used in the United States for 90 years, but recent advances in human milk science and laboratory techniques have led to increasing use of this resource. Pediatricians began using donor human milk in the 1900s in response to anecdotal observation that premature infants had better health outcomes when receiving their own mothers’ milk. Since then, a formalized human milk-banking system developed in the mid-1980s and distributed 1 million ounces of pasteurized donor human milk in 2008. Despite growth in the use of pasteurized donor human milk, there is little discussion in the medical literature regarding the ethical considerations of collection and use of this resource. Key ethical considerations include issues surrounding medical decision-making and informed consent, increasing the limited supply of human milk, how ethically to allocate this scarce resource, and concerns linked to the marketing of a human milk. Pediatrics 2011;128:1186–1191 When mothers’ own milk (MOM) is not available, it is possible to provide humanmilk to premature or term newborn infants that is donated by lactating mothers. In the United States, a system of 10 human milk banks function to collect, store, and distribute pasteurized donor human milk (PDHM) for infants whose physicians may order PDHM feedings as part of their overall plan of care. The use of PDHM is growing in hospital and outpatient settings and raises important ethical issues for clinicians, hospitals, and parents that have not yet been systematically examined. In this article, we review the history, current state of, and ethical issues surrounding human milk-banking in the United States. Key ethical considerations include issues surrounding medical decision-making and informed consent, increasing the limited supply of human milk, how ethically to allocate this scarce resource, and concerns linked to the marketing of PDHM and infant formula. HISTORY AND CURRENT STATE OF HUMAN MILK-BANKING “Donor banked milk” was first mentioned in the medical literature in 1914 when a physician observed that ill children “do very much better if they are fed wholly or in part on human milk.”1 Throughout the 1920s and 1930s the absence of refrigeration and variation in pasteurization techniques largely precluded the preservation of humanmilk. Because of these limitations, providing donated milk for newborn and ill infants who did not have access to their MOM required donors to reside in close proximity to the hospital nursery. An early system for providing donated human milk was formalized as the Boston Wet Nurses Directory for infants who did not have access to their MOM.2 Other hospitals throughout the United States also developed wet-nurse systems for AUTHORS: Donna J. Miracle, PhD, MSN, RN,a,b,c Kinga A. Szucs, MD, IBCLC,d,e,f,g,h,i Alexia M. Torke, MD, MS,c,e,j,k,l and Paul R. Helft, MDc,e,m,n aRush University College of Nursing, Chicago, Illinois; bIndiana Mothers’ Milk Bank, Inc, Indianapolis, Indiana; cCharles Warren Fairbanks Center for Medical Ethics, Indiana University Health, Indianapolis, Indiana; Divisions of dPediatrics, jGeneral Medicine and Geriatrics, and mHematology/Oncology and eDepartment of Medicine, Indiana University School of Medicine, Indianapolis, Indiana; fRiley Hospital for Children, Indianapolis, Indiana; gNewborn Nursery, Wishard Health Services, Indianapolis, Indiana; hAmerican Academy of Pediatrics Section on Breastfeeding Executive Committee, Elk Grove Village, Illinois; iAcademy of Breastfeeding Medicine, New Rochelle, New York; kIndiana University Center for Aging Research, lRegenstrief Institute, Indianapolis, Indiana; and nIndiana University Melvin and Bren Simon Cancer Center, Indianapolis, Indiana