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HUMAN MILK BANKS
284 HUMAN MILK BANKS
SIR,-I glad that Dr Lucas (Jan. 9, p. 103) has spoken out indiscriminate the promotion of banked breast milk for against premature babies. This ill-advised campaign could easily lead to complications and even deaths. The modified milks currently used for artificial feeding are safe and convenient, and even the smallest premature babies thrive on them. There are many serious misits use in preterm infants should be left givings about breast to those with the resources and interest to find the answers. am
milk; 1,2
Human milk is no more physiologically adapted for the 1 - 5 kg premature baby than is the shape or size of the organs which produce it. Premature babies fed on expressed breast mik grow less well than those given a modified cows’ milk formula, this giving rise 3 to concern about later physical and intellectual development. Babies who grow more slowly leave hospital later, ironically jeopardising the hoped-for establishment of natural breastfeeding, perhaps one of the main reasons for using breast milk in the first instance. The smallest babies may take 6 weeks or more to regain their birthweights. Hyponatraemic protein-calorie malnutrition is now a common problem in special care baby units when unsupplemented breast milk is used. These deficiencies can be avoided by the careful routine addition of casein, ’Caloreen’, sodium, calcium, iron, and vitamins but not without adding to the already exacting work of SCBUs, and then there is the problem of uninformed naturopaths who resist adding to the milk for fear that it may damage its "natural goodness".
Of equal if not greater concern is bacterial contamination. Escherichia coli, Staphylococcus aureus, and 0-haemolytic streptococci abound,4even in milk freshly expressed by sterile pumps after handwashing and cleansing the nipple.The immunity of breast fed babies from infection is a myth. Human milk is powerless against pathogens, and in 1981 I saw three very serious infections in fully breast fed term babies-one streptococcal osteomyelitis, one staphylococcal cervical abscess, and one bullous impetigo-all of whom acquired their infection from the mother’s breast or milk. The preterm infant has little transplacental passive immunity and many are already struggling for survival. An outbreak ofklebsiella septicaemia with one death in a SCBU and was traced to contaminated donor milk.Despite the long list of antibacterial factors (which should include the occasional excretion of antibiotics, hexachloraphane, and DDT), viable bacteria readily flourish in human milk. One or two drops of dilute are more effective in reducing the bacterial population than all the natural factors put together.
hypochlorite
prolonged jaundice12 and haemorrhagic disease. 13 The problems of milk banking were discussed in an excellent editorial and are well covered in a guide by Baum et al. 14 The Department of Health should harbour no illusion that milk banks can be accomplished cheaply. Proper breast milk banking needs people, pasteurisers, pumps, freezers, maintenance, repairs, laboratory time, supplements, travel expenses, and the cost of having to keep babies longer in hospital. Compared with ready-to-feed modified formulae, human milk is very expensive. Many SCBUs are already short of staff, equipment, and money and depend heavily on public goodwill and private charity. I am reluctant to feed babies the lymphocytes and macrophages of other mothers and am not prepared to use donor milk under any circumstances. Our policy is to use the mother’s milk freely in babies over 2 kg provided they are well; milk collected the same day is used fresh, otherwise it is heated; no routine laboratory checks are done but supplements of calcium are given in the first week, of sodium until the baby goes home, and of iron and vitamins until the age of six months. Expressed breast milk is not used in babies under 1 -5kg and only reluctantly in babies between 1 -5and 2 -0kg on condition that it is heated, fully supplemented, and periodically monitored for organisms and drugs. Existing milk banks have shown how to produce a reasonably acceptable product but they must now demonstrate that they achieve superior results unless, as Lucas points out, we are to open another chapter of iatrogenic neonatology. The cavalier feeding ofunsterile unsupplemented breast milk to small premature babies in the blind faith that it is full of natural goodness and antibacterial protection of unsurpassable potency should be strongly condemned. Special Care Baby Unit, Charing Cross Hospital,
HERBERT BARRIE
London W6 8RF
FIVE-YEAR FOLLOW-UP OF NON-DIABETES WITH ISLET-CELL ANTIBODIES
SiR,—Dr Gorsuch and colleagues (Dec. 19/26, p. 1363), in a prospective study of non-diabetic first-degree relatives of type i diabetics, observed the onset of overt diabetes mellitus (DM) in seven subjects. All were positive for conventional islet-cell antibodies (ICA-IgG) and six also had complement-fixing islet-cell antibodies (CF-ICA). We have, for 5 years, been monitoring the glucose tolerance in and of sixteen ICA-positive non-diabetics, fifteen with autoimmune manifestations. At least once a year every patient was studied by oral’glucose tolerance test, by arginine test, and by determination of ICA-IgG and CF-ICA.1All had a normal body weight for age, sex, and height. Seven had a family history of DM (see table). All known to have endocrine deficiencies were on replacement therapy and patients with active Graves’ disease were taking antithyroid drugs. At the start of the study the serum from all sixteen subjects was ICA-IgG positive and in six cases the serum was CF-ICA positive also. During follow-up three subjects (cases 13,14, and 16), who had been consistently positive for ICA-IgG and for CF-ICA, have acquired diabetes 6, 3, and 8 months from the start of immune
status
one or more
Other infective hazards of unheated milk include virus diseases, especially cytomegalovirus infection and hepatitis, and monilia. Even after pasteurisation, the problem of spores and toxins remains. The possible excretion of undesirable drugs cannot be neglected, including alcohol9 and nicotine. 10 Fad diets may affect the quality of the milk and cause serious harm. 11 Other disadvantages include 1. Editorial. The special care of human milk. Br Med J 1978; 2: 781-82. 2. Fomon SJ, Zeigler EE, Vasquez HD. Human milk and the small premature infant. Am J Dis Child 1977; 131: 463-67. 3. Davies DP. Adequacy of expressed breast milk for early growth of preterm infants. Arch 4. 5.
6.
7. 8. 9. 10.
11.
Dis Childh 1977; 52: 296-301. Lucas A, Roberts CD. Bacteriological quality control in human milk-banking. Br Med J 1979; i: 80-82. Pittard WB, Hack M, Fanaroff AA. Notes on fresh human milk banking at Rainbow Babies’ and Children’s Hospital. Report of 11th Ross Roundtable on Counselling the Mother on Breast-Feeding, 1980; 66-67. Donowitz LG, Marsic FJ, Fisher KA, Wenzel RP. Contaminated breast milk: a source of klebsiella bacteremia in a newborn intensive care unit. Revi Infect Dis 1981; 3: 716-20. Jelliffe DB, Jelliffe EFP. Breast milk and infection. Lancet 1981; ii: 419. Lloyd Jones C, Jennison RF, D’Souza SW. Bacterial contamination of expressed breast milk. Br Med J 1979; ii: 1320-22. Binkiewicz A, Robinson MJ, Senior B.Pseudo-Cushing syndrome caused by alcohol in breast milk. J Pediatr 1978; 93: 965-67. Perlman HH, Dannenberg AM, Sokoloff N. The excretion of nicotine in breast milk and urine from cigarette smoking. Its effect on lactation and the nursling. JAMA 1942; 120: 1003. Higginbottom MC, Sweetman L, Nyhan WL. B 12 deficiency syndrome in a breast-fed infant of a vegan. N Engl J Med 1978; 299: 317-23.
the
study, respectively (see table).
Case 13.-A 64-year-old woman with HLA haplotype A 1, A3, B8. Her brother has type i DM. At age 57 Graves’ disease developed and she was treated with radioiodine and then with methimazole. At that time thyroid microsomal antibodies, thyroglobulin antibodies, ICAIgG, and CF-ICA were found. 6 months later type i DM developed, and in 1981 she was still ICA-IgG and CF-ICA positive. 12. Gartner LM, Arias IM. Studies of J Pediatr 1966; 68: 54.
prolonged neonatal jaundice in the breast-fed infant
13. Kennan 14.
WJ, Jewett T, Glueck HI. Role of feeding and vitamin K in hypoprothrombinaemia of the newborn. Am J Dis Child 1971; 121: 271-77. Baum JD, Fischer C, Smith A. A guide to human milk banking. Vickers Medical Publication, Vickers Ltd. C, Caretto A, Tiengo A, Trevisan A. Complement-fixing islet-cell antibodies
1. Betterle in
type I diseases and i: 1418-19.
1980;
in
susceptible patients with
autoimmune
diseases. Lancet
SIR,-I glad that Dr Lucas (Jan. 9, p. 103) has spoken out indiscriminate the promotion of banked breast milk for against premature babies. This ill-advised campaign could easily lead to complications and even deaths. The modified milks currently used for artificial feeding are safe and convenient, and even the smallest premature babies thrive on them. There are many serious misits use in preterm infants should be left givings about breast to those with the resources and interest to find the answers. am
milk; 1,2
Human milk is no more physiologically adapted for the 1 - 5 kg premature baby than is the shape or size of the organs which produce it. Premature babies fed on expressed breast mik grow less well than those given a modified cows’ milk formula, this giving rise 3 to concern about later physical and intellectual development. Babies who grow more slowly leave hospital later, ironically jeopardising the hoped-for establishment of natural breastfeeding, perhaps one of the main reasons for using breast milk in the first instance. The smallest babies may take 6 weeks or more to regain their birthweights. Hyponatraemic protein-calorie malnutrition is now a common problem in special care baby units when unsupplemented breast milk is used. These deficiencies can be avoided by the careful routine addition of casein, ’Caloreen’, sodium, calcium, iron, and vitamins but not without adding to the already exacting work of SCBUs, and then there is the problem of uninformed naturopaths who resist adding to the milk for fear that it may damage its "natural goodness".
Of equal if not greater concern is bacterial contamination. Escherichia coli, Staphylococcus aureus, and 0-haemolytic streptococci abound,4even in milk freshly expressed by sterile pumps after handwashing and cleansing the nipple.The immunity of breast fed babies from infection is a myth. Human milk is powerless against pathogens, and in 1981 I saw three very serious infections in fully breast fed term babies-one streptococcal osteomyelitis, one staphylococcal cervical abscess, and one bullous impetigo-all of whom acquired their infection from the mother’s breast or milk. The preterm infant has little transplacental passive immunity and many are already struggling for survival. An outbreak ofklebsiella septicaemia with one death in a SCBU and was traced to contaminated donor milk.Despite the long list of antibacterial factors (which should include the occasional excretion of antibiotics, hexachloraphane, and DDT), viable bacteria readily flourish in human milk. One or two drops of dilute are more effective in reducing the bacterial population than all the natural factors put together.
hypochlorite
prolonged jaundice12 and haemorrhagic disease. 13 The problems of milk banking were discussed in an excellent editorial and are well covered in a guide by Baum et al. 14 The Department of Health should harbour no illusion that milk banks can be accomplished cheaply. Proper breast milk banking needs people, pasteurisers, pumps, freezers, maintenance, repairs, laboratory time, supplements, travel expenses, and the cost of having to keep babies longer in hospital. Compared with ready-to-feed modified formulae, human milk is very expensive. Many SCBUs are already short of staff, equipment, and money and depend heavily on public goodwill and private charity. I am reluctant to feed babies the lymphocytes and macrophages of other mothers and am not prepared to use donor milk under any circumstances. Our policy is to use the mother’s milk freely in babies over 2 kg provided they are well; milk collected the same day is used fresh, otherwise it is heated; no routine laboratory checks are done but supplements of calcium are given in the first week, of sodium until the baby goes home, and of iron and vitamins until the age of six months. Expressed breast milk is not used in babies under 1 -5kg and only reluctantly in babies between 1 -5and 2 -0kg on condition that it is heated, fully supplemented, and periodically monitored for organisms and drugs. Existing milk banks have shown how to produce a reasonably acceptable product but they must now demonstrate that they achieve superior results unless, as Lucas points out, we are to open another chapter of iatrogenic neonatology. The cavalier feeding ofunsterile unsupplemented breast milk to small premature babies in the blind faith that it is full of natural goodness and antibacterial protection of unsurpassable potency should be strongly condemned. Special Care Baby Unit, Charing Cross Hospital,
HERBERT BARRIE
London W6 8RF
FIVE-YEAR FOLLOW-UP OF NON-DIABETES WITH ISLET-CELL ANTIBODIES
SiR,—Dr Gorsuch and colleagues (Dec. 19/26, p. 1363), in a prospective study of non-diabetic first-degree relatives of type i diabetics, observed the onset of overt diabetes mellitus (DM) in seven subjects. All were positive for conventional islet-cell antibodies (ICA-IgG) and six also had complement-fixing islet-cell antibodies (CF-ICA). We have, for 5 years, been monitoring the glucose tolerance in and of sixteen ICA-positive non-diabetics, fifteen with autoimmune manifestations. At least once a year every patient was studied by oral’glucose tolerance test, by arginine test, and by determination of ICA-IgG and CF-ICA.1All had a normal body weight for age, sex, and height. Seven had a family history of DM (see table). All known to have endocrine deficiencies were on replacement therapy and patients with active Graves’ disease were taking antithyroid drugs. At the start of the study the serum from all sixteen subjects was ICA-IgG positive and in six cases the serum was CF-ICA positive also. During follow-up three subjects (cases 13,14, and 16), who had been consistently positive for ICA-IgG and for CF-ICA, have acquired diabetes 6, 3, and 8 months from the start of immune
status
one or more
Other infective hazards of unheated milk include virus diseases, especially cytomegalovirus infection and hepatitis, and monilia. Even after pasteurisation, the problem of spores and toxins remains. The possible excretion of undesirable drugs cannot be neglected, including alcohol9 and nicotine. 10 Fad diets may affect the quality of the milk and cause serious harm. 11 Other disadvantages include 1. Editorial. The special care of human milk. Br Med J 1978; 2: 781-82. 2. Fomon SJ, Zeigler EE, Vasquez HD. Human milk and the small premature infant. Am J Dis Child 1977; 131: 463-67. 3. Davies DP. Adequacy of expressed breast milk for early growth of preterm infants. Arch 4. 5.
6.
7. 8. 9. 10.
11.
Dis Childh 1977; 52: 296-301. Lucas A, Roberts CD. Bacteriological quality control in human milk-banking. Br Med J 1979; i: 80-82. Pittard WB, Hack M, Fanaroff AA. Notes on fresh human milk banking at Rainbow Babies’ and Children’s Hospital. Report of 11th Ross Roundtable on Counselling the Mother on Breast-Feeding, 1980; 66-67. Donowitz LG, Marsic FJ, Fisher KA, Wenzel RP. Contaminated breast milk: a source of klebsiella bacteremia in a newborn intensive care unit. Revi Infect Dis 1981; 3: 716-20. Jelliffe DB, Jelliffe EFP. Breast milk and infection. Lancet 1981; ii: 419. Lloyd Jones C, Jennison RF, D’Souza SW. Bacterial contamination of expressed breast milk. Br Med J 1979; ii: 1320-22. Binkiewicz A, Robinson MJ, Senior B.Pseudo-Cushing syndrome caused by alcohol in breast milk. J Pediatr 1978; 93: 965-67. Perlman HH, Dannenberg AM, Sokoloff N. The excretion of nicotine in breast milk and urine from cigarette smoking. Its effect on lactation and the nursling. JAMA 1942; 120: 1003. Higginbottom MC, Sweetman L, Nyhan WL. B 12 deficiency syndrome in a breast-fed infant of a vegan. N Engl J Med 1978; 299: 317-23.
the
study, respectively (see table).
Case 13.-A 64-year-old woman with HLA haplotype A 1, A3, B8. Her brother has type i DM. At age 57 Graves’ disease developed and she was treated with radioiodine and then with methimazole. At that time thyroid microsomal antibodies, thyroglobulin antibodies, ICAIgG, and CF-ICA were found. 6 months later type i DM developed, and in 1981 she was still ICA-IgG and CF-ICA positive. 12. Gartner LM, Arias IM. Studies of J Pediatr 1966; 68: 54.
prolonged neonatal jaundice in the breast-fed infant
13. Kennan 14.
WJ, Jewett T, Glueck HI. Role of feeding and vitamin K in hypoprothrombinaemia of the newborn. Am J Dis Child 1971; 121: 271-77. Baum JD, Fischer C, Smith A. A guide to human milk banking. Vickers Medical Publication, Vickers Ltd. C, Caretto A, Tiengo A, Trevisan A. Complement-fixing islet-cell antibodies
1. Betterle in
type I diseases and i: 1418-19.
1980;
in
susceptible patients with
autoimmune
diseases. Lancet