Dr. Prajwal Paudel

To have the best possible start in life is a basic right of every newborn baby. For optimal nutrition and immunological protection of the newborns, the choice of feeding is to latch the baby directly to mother’s breast or provide expressed milk from own mother, and then pasteurised donated human milk.
However, many babies are deprived of mother’s milk and are given formula feeds because of baby’s inability to suck due to prematurity, being too small to suck or ill, or maternal illness, abandonment or death, and sometimes due to delay in milk production.

Breast milk, which is the  exclusive source of nutrition for the initial  six months of life and a vital part of a child’s diet for the next two years or more, is superior to alternatives like bovine milk or formula in terms of nutritive value, immune function, and functionality of other bioactive and growth factors. It is not uncommon to see problems like vomiting, diarrhoea, indigestion, constipation, allergies, delayed growth, respiratory problems and increased hospitalizations in babies who are deprived of mother’s milk.

Low Breastfeeding Rates
Almost all mothers receive counselling from nursing staff, doctors and other healthcare workers to start breastfeeding within one hour of birth and exclusive breastfeeding for at least six months.
However, it is quite common to see a powder formula milk by the bedsides of  recently delivered mothers in hospitals or at home, especially if she has undergone an operation to deliver the baby, or if she is a working mother or a mother having breast problems or when the baby is unable to suck directly from breast. Worldwide, 42% and 41% of the babies are breastfed within an hour of life and for six months. Had it been possible to provide mother’s milk or donated breast milk to the babies, nearly 12 % of the under-5 child deaths worldwide could be averted by preventing them from possible gastrointestinal, respiratory and other health problems.
Hence, the cost of undermining breastfeeding is enormous. New products claimed to replicate mother’s milk have entered the lucrative market for infant formula and powerful marketing is exploiting the gaps created by inadequate societal support for breastfeeding. It is high time to set up milk banks and ensure the right nutrition for babies in order to protect breastfeeding and protect our children from possible short and long-term harms.

What is Human Milk Bank?
HMB is a service that helps to collect the donated milk from the mothers and thereafter process, screen, store and dispense it to meet the demand of babies who need it. A well-functioning and effective HMB system requires few operational processes to provide safe and high quality donor milk to the babies.
Human milk bank was first set up in Austria in 1909; then in America and South American nations; and its contribution as a pillar for increased child survival has prompted its initiation in South Asian countries like Thailand, India and Philippines.  Currently, there are more than 600 milk banks worldwide and around 50 in India. For the implementation of a successful HMB system, the following components are required-
A dedicated team comprising of lactation management health worker to counsel mothers and help for expression, milk bank technician pasteurisation of breast milk and microbiological surveillance, milk bank attendant for sterilisation of the containers and maintaining hygiene along with strong management support for planning and evaluating the service.
Sufficient space to prepare, screen, pasteurize, and store donor milk and to make donors feel comfortable donating their breast milk.
Equipment like pasteurizer, deep freezer, refrigerator, autoclave, breast pumps, containers and a generator to ensure continuous power supply and a milk analyzer to have a macronutrient analysis of breast milk to estimate calorie, protein and fat of milk sample.
Donor recruitment strategies using promotional media in facilities and community Serological screening for infectious diseases.

Our Specific Needs
Donating breast milk is an ancient practice in Nepal and throughout history, women have breastfed infants who were not their own. In Nepal, institutional deliveries increased from 8% in 1996 to 57% in 2016. Similarly, the population based CS rates increased by 10 folds from 0.9% to 10.2% during the same period.
Presently, around 81000 babies are born preterm in Nepal and contribute to 33% of the neonatal mortality followed by birth asphyxia and neonatal sepsis that account for 23% and 17 % of the neonatal deaths respectively. Babies born via Caesarean sections, born preterm or needing admission for infections and other problems are the babies who are largely fed on infant formula. Donor milk can provide a bridge to successful breastfeeding when a new mother may be facing challenges in establishing her own milk supply. Donor milk can be life-saving for preterms.
It is especially protective against a life-threatening condition called necrotizing enterocolitis, which affects 1 in 10 of small preterm babies. Human milk is estimated to lower this condition by 79%. Currently, only 18% of the babies are breastfed within the first hour of life as recommended and 66 % are exclusively breastfed for six months. All these factors necessitate the establishment of a human milk bank in our set up to ensure basic nutrition to newborns and children.
By 2016, only two public hospitals located in the capital had NICU services, and now this has been scaled up to more than 30 where small and sick newborns are managed. Hence, though not implemented yet, Nepal holds convincing opportunities for flourishing the use of donated mother’s milk for improved survival of babies. If we can integrate human milk banks into our existing newborn care system, it will provide a solid foundation to promote breastfeeding and other best practises for newborn care.One of the major causes of newborn, infant and under-5 mortality has been poor nutrition and malnutrition.
This can be overcome if breastfeeding practises are not substituted by powdered milk from the market but by breast milk provided from milk banks at time of need. This is in turn a vital step to achieve the Sustainable Developmental Goal (SDG) target of reduction in neonatal mortality rate and under 5 mortality rate to less than 12 per 1000 livebirths and 22 per 1000 live-births respectively by 2030.
 
  Rays of Hope
Millions of people are celebrating breastfeeding week by participating in a wide variety of activities to protect, promote and support breastfeeding with the present theme, Breastfeeding: A shared responsibility. In Nepal, the present breastfeeding week has brought promising hope in this context. Finally, it seems like the long wait to establish our first own human milk bank is over with the commitment from the concerned authorities of Ministry of Health and population.
Also, as recently published in a national newspaper, Paropakar Maternity and Women’s Hospital would be the preferred site. It is adorable to learn about the ongoing endeavours from the hospital side to set up nation’s first Human milk bank in the next 3 months. Pioneering something is never easy. However, with hard work, strong commitment and sound leadership, it seems like this new initiative will be serving our newborns and children soon.

(Dr. Paudel is a consultant paediatrician at Paropakar Maternity and Women’s Hospital)