Breastfeeding Medicine

Physicians blogging about breastfeeding

Online milk sales, beyond “buyer beware”

with 35 comments

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.

Written by astuebe

October 21, 2013 at 5:38 pm

35 Responses

Subscribe to comments with RSS.

  1. Oh my, Alison– completely brilliant… Thank you! Ann Conlon-Smith, IBCLC

    aconsmith

    October 21, 2013 at 7:05 pm

  2. We love you and we love your work. Well said.

    Jeanette Mesite Frem

    October 21, 2013 at 9:24 pm

  3. This response is pretty much perfect.

    Tiffany Gallagher

    October 21, 2013 at 10:37 pm

  4. I din’t even know there were sites that sell human milk. I live in Mexico and it never occurred to me that could happen. I know about milk banks inside hospitals that are for new borns (with its own mother’s milk). I believe breast milk coming from a healthy woman has a lot of bacteria as part of its natural composition that have a purpose to be there. The use it is given after it has been expressed is very delicate and should have strict controls. I agree that more information should be provided to mothers so each can produce their own in enough quantities as nature intended us to make. Also, it is important to provide information to make sure formula fed babies receive their formula in good conditions to avoid any contamination.

    Monica

    October 21, 2013 at 10:50 pm

  5. Excellent article, thank you. However, I think this bit is misleading “Therefore, both the World Health Organization the Centers for Disease Control and Prevention recommend feeding all newborn babies liquid formula.” Surely this only applies to formula-fed newborns rather than all newborns as stated? What about breastfed newborns?

    Fiona Harford

    October 22, 2013 at 2:43 am

    • You are absolutely right — have edited the sentence to make clear that WHO and CDC recommend that formula-fed babies get liquid, not powdered, formula. Thanks for catching this!

      astuebe

      October 22, 2013 at 6:00 am

  6. Thank you Alison for this logical and thoughtful response. Of course mothers can safely share their milk. This practice benefits many families who might otherwise have no other options than to use formula. Nothing we consume is sterile, nor should it be. Bacteria in human milk is good for the infant gut and the immune system. Sadly there is much opposition to informal milk sharing. When done in an appropriate, safe manner by caring mothers who understand proper handling and storage, shared milk is always preferable to infant formula.

    Rachelle Lessen

    October 22, 2013 at 5:58 am

  7. […] truth”, I believe, is floating somewhere in the middle. As Alison Stuebe, MD, points out on her Academy of Breastfeeding Medicine blog, this study was limited by its methodology. The breastmilk samples were obtained through an online […]

  8. Thank you, Alison

    Aunchalee Palmquist

    October 22, 2013 at 7:19 am

  9. Bravo! A very well-expressed, counterpoint article. I appreciate you pointing out the flaws of that study in such a cohesive and well-researched fashion.

    lrivera

    October 22, 2013 at 9:14 am

  10. What I take from the study is that people need to be a lot more discriminating about how they obtain breast milk. Perishable food shipped without precautions is dangerous. Seriously, no dry ice?!? Also, I understand that formula is not sterile but I have never heard of or read about any baby getting sick off formula that wasn’t because of dirty water, allergies/intolerances (I hear more about these from BFing moms than I ever do by FF moms, BTW), foreign objects (exceedingly rare), or parental error (feeding too old milk, etc). I’m 100% for increasing standards for formula as needed, just like with any food, but just by the sheer number of users over such a large amount of time I think formula’s description as ‘dangerous’ is a tad extreme. Both my babies receive BM but I have and do supplement.l

    bonnie

    October 22, 2013 at 9:46 am

    • Hi Bonnie – the issue w/ milk preparation is primarily about a bacteria called Cronobacter that can cause life-threatening infections in newborns. There is information on the CDC web site here:
      http://www.cdc.gov/features/cronobacter/ There is a case series published about babies who died of cronobacter here: http://wwwnc.cdc.gov/eid/article/12/8/pdfs/05-1509.pdf What’s worrisome to me is that most parents have no idea that the WHO and CDC recommendations on formula preparation exist. As with any parenting recommendations, some families will make a decision that the absolute risk is small, but I believe health care providers should give families the information to make that decision for themselves.

      astuebe

      October 22, 2013 at 10:54 am

      • I don’t know what the standard containers are like elsewhere in the world, but here in Canada ALL infant formulas have clear instructions on them regarding sterilization & preparation. Every mother I know personally that formula fed was also well aware of the need to sterilize bottles and water before feeding it to our babies. Also in regard to the “tip” about leaving the bottle, water & formula at the bed side – you’re assuming the mother isn’t using sterilized bottles & water simply because she didn’t explicitly say so. Anyone who has sterilized water for an infant bottle has to allow it to cool before giving it to your child or it would burn them! Your inaccuracies and assumptions regarding formula feeding parents is disappointing and takes away from the argument in your article.

        torrielynn

        October 24, 2013 at 4:02 pm

      • Hi Torrielynn –

        That’s great to hear that the labels are so clear in Canada. In the US, the labeling is much less explicit. I went to the grocery store before I wrote this blog — here’s a photo of a powered formula package:

        http://j.mp/167aVMr

        “Ask your baby’s doctor if you need to use cooled, boiled water for mixing and if you need to boil (sterilize) bottles, nipples and rings before use.”

        I suspect many parents of healthy newborns think these instructions mean that they do not need to boil water to prepare milk for their babies.

        I also searched the web site I quoted regarding preparing formula in the middle of the night for the word “sterilize.” It shows up in two articles, one about bottles and one about pumping breast milk.

        The bottle article says:

        http://j.mp/17hELkj

        Q: What’s the best way to clean a bottle?

        A: “Sterilize new parts and nipples in boiling water for five minutes before the first use,” Dr. Landau says. After that, a thorough wash in hot, soapy water is fine.

        The pumping article says:

        http://j.mp/17hELRf

        Keep It Clean

        After each pumping session, disconnect washable pumping parts from the tubing, place them in a bag, and put them in the fridge to “decrease bacterial count between pumping sessions,” Lewis says. Or soak the parts in hot, soapy water. Wipe down electrical units and batteries, but don’t submerge them. Every four to five days, sterilize washable parts in a pot of boiling water, the top rack of the dishwasher (check manufacturer’s recommended washing instructions first), or in a microwave sterilizer bag.

        It’s striking to me that the site says bottles only need to be sterilized once, whereas pump parts need to be sterilized every 4 to 5 days. I suspect that formula companies deliberately recommend a more complicated regimen for pumping, because every time a baby is fed breast milk, a formula company loses a sale.

        I would argue that families deserve clear information, on the packaging, about CDC and WHO guidelines for formula preparation — and I do not think the US packaging meets that standard.

        astuebe

        October 24, 2013 at 4:51 pm

  11. Brilliant commentary, thank you!

    jodinechase

    October 22, 2013 at 9:48 am

  12. Thank you for this thoughtful post. I was not aware of paid online milk sharing but I have shared milk with other mothers in a mothers’ group through my birth center. It was a wonderful feeling knowing that someone could benefit from milk that I did not need (I already produce enough for my little one.) I think you hit the nail right on the head though about it being a “women and their dirty feminine fluids” thing. How strange that something so culturally the norm in other times and areas can be so taboo here. But then again, look at our entire response to women breastfeeding, especially in public or past an “appropriate age” so it isn’t that surprising.

    Ashley

    October 22, 2013 at 10:16 am

  13. To me it’s almost like the scientists’ efforts at creating impartiality (by not allowing any conversation between milk provider and user) may have inadvertently created a selection bias. Providers who were less concerned with the recipients’ needs seem to have been the ones who kept in touch with the scientists, and perhaps that translated into less care with cleanliness. Had the scientists had a more honest but unbiasing conversation (“Well, we’d like to study naturally occurring factors in the milk, not give it to a specific baby”) I bet more of those women who dropped away would have participated and the results might show less contamination.

    Sarah

    October 22, 2013 at 10:25 am

  14. Don’t forget that breastmilk has numerous factors that kills the bacteria from contamination. Breastmilk obtained directly from the breast under strict hygienic conditions also contains bacteria.

    Touraj Shafai, M.D.Ph.D.

    October 22, 2013 at 2:05 pm

  15. […] A blog post at Breastfeeding Medicine, pointed out by a reader, makes some good points about limitations in this study’s […]

  16. I’m from Brazil, and as a reader from Mexico has pointed out, here, too, we wouldn’t think of sharing breastmilk online, let alone in exchange for money! It sounds like selling a kidney or blood (well, it is legal in some countries, too…). We also have human milk banks, that make sure, first of all, that the breastmilk donnor is not infected with STD’s. Then, they teach women how to collect it, in order to prevent contamination, and some centers even give out the containers for the donnors. The milk is then frozen, and given to babies who need it. When I had my second child, by the third day, I had so much milk that my normally small boobs looked like Pamela Anderson’s! I felt really sad that I lived in a small village in the countryside, so, there wasn’t a breastmilk bank around to which I could donate my milk. Many times, I had to milk myself, and pour it down the sink. My mother said it’s bad luck to waste breastmilk, çause it’s so precious, but what could I do?

    Verônica

    October 22, 2013 at 8:12 pm

  17. Thank you Doctor Stuebe, I’m not sure if you remember me or not but I saw you up at UNC. I had the 27 weeker after an appendectomy at 25weeks. A is doing wonderful now weighing over 16lbs, and is 9months this week. He has actually been on donor milk ever since we left the NICU. Thank you for all you do! I will never forget this statement you said to me ” if you lived in a village and this happened to you, another mama would have just fed your baby” well, baby A has been fed by well over 15 mamas, and I’m so thankful for mamas who can and will donate to babies in need.

    elizabethstrysko

    October 22, 2013 at 9:26 pm

  18. I love how quickly you respond to these “studies” which create so much hysteria. You are the woman! IBCLCs love you!!

    Sharen Medrano

    October 23, 2013 at 8:10 am

  19. Perhaps someone should suggest to the authors of the study that they perform a follow up study, where they contact random people selling artificial baby milk and have them prepare it as they normally would then and ship it to them under same conditions, and then perform the same cultures.

    This study seems to have been designed specifically to produce the most adverse results.

    Hartfa

    October 23, 2013 at 8:38 am

  20. […] it first in the write up on it in the New York Times. Once you get over the shock and the horror, read the educated and informed editorial on it from the blog for the Academy of Breastfeeding […]

  21. This study — edited, we know — does have a few loopholes that readers have pointed out, that more space or time might have avoided in the first place. I donated, at my own expense, excess breastmilk to a private party for almost a year, the arrangement having been set up by our LC’s. The receiving mom fully vetted my health condition via self-reported rx use post partum, and my hospital lab’s results from Hep and HIV testing. I also learned of her reasons for needing donated milk, and her family’s health & welfare. The recipient’s child was able to consume breastmilk exclusively for his first year. Without our conscientious approach and a link via our LC’s, neither one of us would have dreamed of donating to nor feeding my breastmilk to this child in need. The best lessons that I lived and learned, to the benefit of both our families were “Mothers, beware, be kind, be accountable.”

  22. Thank you for this clear and concise research critique. I love the line: “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” – aint that the truth!

    Tamara

    October 23, 2013 at 9:21 pm

  23. […] You can read the full article here: “Online milk says, beyond buyer beware.” […]

  24. […] know there is bacteria in milk, and that there is supposed to be. Dr. Alison Stuebe points out in a blog post for the Academy of Breastfeeding Medicine (ABM), it’s “not clear from the study to what extent […]

  25. Alison’s editorial is brilliant, as she always is. As a neonatologist who uses donor milk routinely in my NICU, and a co-medical director of a developing HMBANA donor milk bank (previously medical director of another HMBANA milk bank), I have spent a lot of time in this field.

    I think it is indisputable that the safest donor milk is that which comes from a donor milk bank, because the donor has been vetted, tested and the milk has been pasteurized. It is the safest donor milk we know of in 2013. At the other end of the spectrum is “milk” bought anonymously on the Internet, knowing nothing about the donor. In between, one can develop a relationship with a donor and find out, as mentioned by Alison and many of the commenters, a donor’s history, blood test results, how they collect and store, ship the milk, and can make an informed decision about how comfortable one feels about obtaining this milk.

    When obtaining anonymous milk on the internet, with no information, one does not know things like if the milk contains drugs, nicotine, whether there are viral infections you don’t know about, how hygienically it has been collected, how it has been stored, how old it is, how old the baby it has been produced for is, if it has been adulterated to increase the volume, or if it is even human milk. There are studies in the transfusion literature that show when people sell blood versus when they donate blood, the blood is much more likely to be contaminated with viruses like hepatitis when being sold. To my knowledge no one had done similar studies in human milk, but one wonders. The reasons for selling (need for income) versus donating (altruistic) are different and could possibly influence the quality of the milk. I am just thinking out loud here.

    The fact that women are on the internet looking for milk means two things to me. One–women “get it”. The high rates of initiation mean that the message is out there–feeding our milk to our babies is important. So we are doing it. But–two–the rapid fall-off of breastfeeding rates and the fact that some women feel so desperate for human milk that they will even buy if from women they know nothing about on the Internet means that we have failed them miserably. We as health care providers, we as society, we as a culture, we as support systems have failed them. And that is what we need to fix. Many of us, many of you are out there every day trying to do just that. And I applaud you for that. But until we fix all these issues, we will have these huge numbers of women trying to find milk, even if it means buying it from women they know nothing about on the Internet. That to me is the real story here. Kathleen Marinelli MD, IBCLC, FABM

    kmarinellimd

    October 25, 2013 at 7:21 pm

  26. […] From Breastfeeding Medicine […]

  27. […] United State Breastfeeding Committee Statement of Safe Use of Donor Human Milk and Online Milk Sales, Beyond Buyer Beware: A new study in Pediatrics has spawned provocative headlines, contrasting images of human milk […]

  28. […] media coverage on the study, the Academy of Breastfeeding Medicine published the blog post, “Online milk sales, beyond ‘buyer beware”, analyzing the study design and news coverage and offering recommendations. AAP News, the official […]

  29. […] of the dangers of  informal milk sharing in his CLC training has prompted Salmon to start free breastfeeding classes which began May […]

  30. […] of the dangers of  informal milk sharing in his CLC training has prompted Salmon to start free breastfeeding classes which began May […]

  31. […] of the dangers of  informal milk sharing in his CLC training has prompted Salmon to start free breastfeeding classes which began May […]


Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s

Follow

Get every new post delivered to your Inbox.

Join 692 other followers

%d bloggers like this: