Online milk sales, beyond “buyer beware”

A new study in Pediatrics has spawned provocative headlines, contrasting images of human milk as “a nourishing elixir, or a bacterial brew.”   Researchers anonymously bought breast milk from 102 online sellers. Milk orders were often packaged poorly, arrived well above freezing, and — as one might expect with milk unrefrigerated for days — were rife with bacteria.

But that’s really not the whole story. First, consider who participated in the study.  By design, the authors communicated with sellers only by email, and cut off the conversation if the sellers asked about the recipient infant or wanted to talk by phone or in person. Milk was shipped to a rented mailbox to make the process anonymous. Of the 495 sellers the authors contacted, 191 sellers never responded, 41 stopped corresponding before making a sale, and 57 were excluded because they wanted to communicate by phone or asked about the recipient baby. Another 105 did not complete a transaction, leaving 102 of the original 495 sellers approached who actually shipped milk. Of these, half the samples took more than 2 days to ship, and 19% had no cooling agent in the package.

It’s highly plausible that milk sent with no questions asked, via 2 day or longer shipment, and (in 1 and 5 cases) without any cooling whatsoever, was collected with less attention to basic hygienic precautions.  The bacterial load in study milk samples therefore doesn’t tell us about the relative safety of milk obtained following a conversation between buyer and seller about the recipient baby and then shipped overnight on dry ice in a laboratory-quality cooler.  Indeed, when the authors compared online milk purchases with samples donated to a milk bank after a screening and selection process, they found much lower rates of bacterial contamination.  The authors acknowledge this limitation in the study, but that subtlety has been lost in the media coverage.

It’s also not clear from the study to what extent bacteria found in milk reflect contamination vs. “good bacteria” that are present in milk.  A growing literature demonstrates that “fresh from the tap” breast milk contains a wide variety of bacteria, and these bacteria colonize the infant’s gut. The study reported in Pediatrics did not distinguish between species of bacteria, nor did they compare the frozen samples with freshly expressed breast milk. The salient question is not, “Is there any bacteria in milk bought online?” but “How much more disease-causing bacteria is present in milk bought online, compared to milk that’s fresh from the breast?”

Moreover, news coverage has not considered the broader context of infection risk in infant feeding.  Powdered infant formula is not sterile. Therefore, both the World Health Organization the Centers for Disease Control and Prevention recommend feeding all formula-fed newborn babies liquid, not powdered, formula. If a newborn is fed powdered formula, the WHO and the CDC  recommend cleaning bottles in a dish washer with hot water and a heated drying cycle, heating water to at least 158 degrees F (70 degrees Celsius) to make formula, and using formula within 2 hours of preparation.

Studies suggest that most parents don’t follow these guidelines. Importantly, formula packaging doesn’t include the CDC language, instead advising parents to “ask your baby’s doctor about the need to sterilize water and preparation utensils before mixing formula.”

Online information from formula companies is even less explicit. In an article titled, “10 Things to Know about Bottle Feeding,” a formula company web site suggests:

If baby wakes you up to eat, try this tip from New York City mom Michele Bender: ‘I’d measure the formula and keep the powder, water, and bottle on my night table. I could mix it right there rather than having to go to the kitchen. It sounds minor, but at 3 a.m., one less step is great.’

These instructions directly contradict WHO and CDC recommendations by suggesting parents use room temperature water to mix  formula.  Given the very large number of infants who are fed powdered formula, inaccurate information on formula preparation is a far greater hazard for infant health than milk bought online.

What we need is education on safe handling of food for infants to minimize the risk of food-borne infection for babies. ABM has published evidence-based guidelines for human milk collection and storage, and HMBANA has developed detailed guidelines on safe milk collection. Broadly disseminating this information will provide mothers who are milk sharing with guidance on how to minimize risk.  Health care providers need to engage families, inquire about milk sharing, and discuss this practice in an informed consent context, rather than dismissing milk sharing as unacceptable. Similarly, we need formula-feeding families to have complete information on how to minimize risk of catastrophic infections.

And then there’s the “ick” factor – what The Verge alluded to in their coverage as “Women and their dirty femine fluids.”

In a provocative essay titled, Milk sharing and formula feeding: Infant feeding risks in comparative perspective?, Karleen D. Gribble and Bernice L. Hausman explore why health authorities proscribe human milk sharing as dangerous, but provide parents with information to assist them in the management of the risks of formula feeding.

There is a well recorded historical legacy of suspicion concerning mothers and their milk. In its current iteration, this suspicion leads to the conclusion that corporations are considered more trustworthy than women to provide healthful nutriment to infants.

Cultural proscriptions around breastfeeding and milk-sharing are not new, but rather reflect centuries of debate about the role of women’s bodies in society. As Lia Moran and Jacob Gilad write in From Folklore to Scientific Evidence: Breast-Feeding and Wet-Nursing in Islam and the Case of Non-Puerperal Lactation:

It should be clear by now that in many societies the rules regarding breast-feeding, were laid down by men, and tend to support male-dominated institutions. For example, in those countries which observe Muslim civil law, the duty of a woman to feed her husband’s children, the duration of feeding and the conditions under which she may feed children other than her own, thus establishing links of milk-kinship, are all prescribed by a male-dominated paternal legal system. The feeding of one woman’s child by another has been used in different societies to make peace between two tribes, to consolidate clan unity, to prevent marriage, to create clients, and in sum, to attain objectives which lie far beyond the nursing woman’s own interest.

Indeed, the nursing woman’s own interest is not part of the discourse around online milk sales. The market for human milk exists because of the mismatch between promoting “breast is best” and prioritizing real support for mothers and babies. Moms buy milk online because they want to breastfeed, but they are unable to meet their infant’s needs with their own milk.  Often, these moms are victims of the “Booby Traps” that stymie so many women, ranging from uninformed health care providers to outdated maternity practices and bottom-of-the-barrel policies for parental leave in the United States.  In other cases, a mother’s body simply can’t make enough milk for her baby, despite heroic efforts to sustain breastfeeding.  We could obviate much of the demand for online milk sales if we changed policies and practices. We might also find ways for more moms  to make enough milk if we devoted a fraction of the resources currently directed at erectile dysfunction to lactation dysfunction.

“Breast milk as bacterial brew” pushes lots of cultural buttons — from the “ick factor” to our reliance on mass-produced and marketed substitutes, rather than women, to nourish our children.  Let’s stop pressing buttons, and start looking for solutions, so that more families can achieve their infant feeding goals.

Alison Stuebe, MD, MSc, is a maternal-fetal medicine physician, breastfeeding researcher, and assistant professor of Obstetrics and Gynecology at the University of North Carolina School of Medicine. She is a member of the board of the Academy of Breastfeeding Medicine. Posts on the ABM blog reflect the opinions of individual authors, not the organization a whole.