This document guides Grampians Health (GH) staff clinical practice when a baby's parent or guardian requests the use of screened or unscreened, unpasteurised donor human breastmilk for feeding their baby. This includes requests for co-breastfeeding.

Parents/guardians who request the use of donor human breastmilk (DHM) for feeding their baby are counselled appropriately about the use of DHM.

Appropriate screening, storage and use of DHM procedures are followed.

Donor Human Milk: (DHM) Breastmilk that is expressed for a baby who is not the womans own biological baby.

Mother: Biological mother (or pregnant woman) of the baby to be fed donor human breastmilk. The term mother will apply to the woman during pregnancy and after birth.

Breastmilk Donor: A woman who is donating breastmilk. Referred to in this document as the 'donor'

CMC Lactation: Clinical Midwife Consultant Lactation.

Co-breastfeeding: Breastfeeding shared by two parents for example in a same-sex relationship where both parents are lactating.

GH: Grampians Health

GH promotes and supports breastfeeding as the best method of infant feeding. In some circumstances, a parent/guardian may request the use of donor human breastmilk for their baby. Indications may vary but may include:

• The mother is not producing enough breastmilk for her baby and wishes to avoid the use of infant formula.

• The mother may be unwell and not able to breastfeed or express for her baby

• There may be a contraindication to the use of the mothers own breastmilk e.g. use of contraindicated medications (rare).

• A surrogacy arrangement where the commissioning mother has elected to induce lactation for the baby.

• A same-sex relationship where another parent is inducing lactation to share the breastfeeding.

In surrocacy and same-sex parenting arrangements, breastmilk provided by a parent who is not the biological mother of the baby is considered to be donor breastmilk in the hospital setting.

GH does not recommend the use of unscreened, unpasteurised human breastmilk as this may present a risk of transmission of infectious agents to babies, such as HIV1 or 2, hepatitis B or C, human T cell lymphtrophic virus (HTLV) type 1 or 2, cytomegalovirus, and syphilis. However, the use of artificial infant formula also carries some risk for babies, which must be balanced against the risks of unscreened, unpasteurised donor human milk.

The presence of alcohol, cigarette toxins, medications and other drugs in donor breastmilk should also be considered.

Parents/guardians have the right to make informed choices regarding their baby's medical care and method of feeding. Where a parent/guardian requests the use of screened, unscreened or unpasteurised donor human breastmilk for their baby who is under the care of GH, this guideline must be followed.

DHM must not be used if the donor:

• Has active herpes simplex virus (HSV), varicella zoster virus (VZV) infection or tuberculosis.
• Is taking medication (including complementary medicines) contraindicated during breastfeeding.
• Is using illicit substances contraindicated during breastfeeding.
• Has any condition in which breastfeeding is normally contraindicated.

Please refer to Appendix 1 of CPP0204 - Breastmilk - Incorrect Breastmilk Administered to a Baby for further information about infections and breastmilk (See link in related documents below)

It is preferable that the parent identifies antenatally (where possible) that they want to use donor breastmilk for their baby. This allows adequate time for discussion and counselling with the parent and potential donors, and screening of donors.

GH strongly discourages the use of donor breastmilk supplied from unknown donors e.g. through the internet due to the risk of infection. Internet purchased breastmilk may be diluted and/or adulterated with non-human milk.

It is important that the baby's parents and donors are educated by GH staff about cleanliness and good hygiene when expressing, storing, handling and transporting expressed donor breastmilk. Refer to CPG0186 - Breastmilk - Expressing, Storing and Feeding - see link in Related Documents below.

If the birth mother plans to breastfeed, she should be provided with skilled support to establish and build her own breastmilk supply to reduce the need for donor breastmilk.

Request for co-breastfeeding.

Co-breastfeeding is a choice sometimes made by parents in same-sex relationships. In this situation, the non-birth parent induces lactation and shares breastfeeding with the birth mother.

Whilst the baby is under the care of GH:

• expressed breastmilk provided by the non-birth parent is considered donor breastmilk

• a request for direct, co-breastfeeding by the non-birth parent is managed the same way as a request for donor expressed breastmilk.

Request for use of donor breastmilk

Where a request is made from a parent/guardian that donor human milk to be given to their baby, a referral should be made to the Clinical Midwife Consultant for Lactation (CMC Lactation). If the CMC Lactation is not available, a senior midwife or nurse should be consulted.

A copy of the Donor Breastmilk Consumer Information pamphlet should be given to the parent/guardian. (See appendix 1)

Discussion between the CMC Lactation and the parent/guardian should include the following points:

• GH does not recommend the use of unscreened unpasteurised donor human milk due to risk of infection, dilution and contamination with non-human milk

• Exploration of the parent/guardian's reasons for requesting the use of donor milk

• Strategies to avoid the need for donor milk such as:

  • Induced lactation if applicable

  • Antenatal expression of colostrum

  • Early initiation of breastfeeding and expressing depending on the circumstances

• Recommended serum screening of potential donors for presence of infections which may be transmitted in breastmilk.

Discussion with breastmilk donor

A confidential discussion should be held between the CMC Lactation and the potential donor. The donor should not have any conditions that would contraindicate breastfeeding. The donor should be:

• in good general health

• negative for infections listed in the blood screening procedure below. The donor should be asked about each condition specifically.

• using only medications and complementary medicines which are compatible with breastfeeding

• not smoking or using alcohol

• not using illicit substances

It is important to discuss with the donor issues related to maintaining an adequate milk supply for her own baby whilst donating surplus breastmilk.

Blood screening procedure

• If the parent/guardian and donor agree to blood screening, the donor should attend her GP and request serum screening. Results of the screening should be forwarded to GH.

• The following serological tests should be performed irrespective of previous screening:

  • HIV antibody - pre-test counselling should be performed by the doctor ordering the serology

  • hepatitis B virus surface antigen (HBsAg)

  • hepatitis C antibody

  • CMV

  • syphilis serology (RPR and TPHA)

  • Human T-cell lymphotropic virus (HTLV) types I and II serology may be indicated if the donor has a family history of adult T-cell leukemia/lymphoma or other associated conditions, or comes from an endemic area (including Japan, Melanesia, the Caribbean, South America and Africa)

• A medical record is to be created for each donor.

• Advise the donor that she should ideally wait for the results of the blood tests before making any donations of milk.

• The CMC Lactation and a medical officer should check blood screening results prior to breastmilk being fed to the baby.

• Results will be confidentially discussed with the donor only.

• The parent/guardian of the intended recipient baby will only be advised that screening indicates that the donor breastmilk will or will not be suitable.

• The donor milk should be discarded if the donor has active herpes simplex virus (HSV), varicella zoster virus (VZV) infection or tuberculosis.

Cytomegalovirus and donor breastmilk

• If the donor is CMV positive, paediatric medical advice should be sought if:

  • The recipient baby is < 32 weeks gestation

  • The recipient baby is unwell

  • The donor is CMV IgM positive

• If the recipient baby's parent/guardian consents to their baby receiving donor breastmilk from a donor who is CMV IgM positive, this should be documented in the baby's medical record.

• The baby should be observed for symptoms of clinical disease and managed accordingly.

• Freezing donor breastmilk for at least 72 hours before use may reduce the risk of CMV transmission.

• Consider paediatric medical advice regarding the baby of a donor who is found to be CMV IgM positive.

If the parent/guardian declines donor screening or will not wait for the results of the donor screening

• Document the parent/guardian's decision in the baby's medical history.

• Ensure Donor Human Breastmilk Waiver form MR055.1 has been signed by the parent/guardian and staff member.

• Parents/guardians must be informed that the hospital will not take responsibility for the giving of unscreened unpasteurised donor human milk - this should be documented in the baby's medical record.

Referral to paediatric medical staff

Routine referral to paediatric medical staff is not required. However if there are relevant medical concerns related to the use of DHM for the baby, paediatric referral should be made.

Documentation

• The parent/guardian should sign the Donor Human Breastmilk Waiver form MR055.1 and this is stored in the baby's medical history. This form should be used for all babies receiving screened or unscreened donor human milk. The form is available in Special Care Nursery, the Postnatal Ward and the Breastfeeding Service office.

• Document in the baby's progress notes that the baby is receiving donor breastmilk.

Transport, storage and use of donor breastmilk

• Donor breastmilk must be labelled with the donor's name, date and time of expression and the identification label of the baby to whom it will be administered.

• Refer to CPG0186 - Breastmilk - Expressing, Storing and Feeding - see link in Related Documents below.

• Staff/parent to document on the infant feed chart whether donor or mother's own breastmilk given at feed times.