1. GLOBAL OVERVIEW AND EVIDENCE
DR. MINNIE KIBORE
KPA ANNUAL SCIENTIFIC CONFERENCE 2019
April 9th 2018

2. Globally, will we reach SDG newborn mortality
8/19/2019
Globally, will we reach SDG newborn mortality
target to achieve <12 deaths/1,000 live births by 2030?
Every region of the world experiencing increase in proportion of <5 deaths in neonatal period
22 countries with high newborn mortality rates will struggle to achieve SDG (majority in Africa)
To achieve the Sustainable Development Goals (SDGs), all countries must reduce newborn deaths to
less than 12 per 1,000 live births by This is an extremely daunting challenge for countries with
rising births and heavy burdens of newborn mortality, almost all of which are in sub-Saharan Africa.
For these countries, identifying and implementing cost-effective strategies to reduce newborn deaths
will be key. Evidence suggests that improving newborn nutrition by increasing early and exclusive human
milk diets is highly cost-effective because it has the potential to reduce both newborn deaths and
healthcare costs.
And more younger babies are living….thriving is critical.
Globally, the neonatal mortality rate fell from 33 deaths per 1,000 live birth in 1990 to 20 in However, the decline has been slower than the decline in the post-neonatal (1-59 months) mortality rate. As a result, neonatal deaths currently represent a larger share of the total under-five deaths than in 1990.
In 2013, about 44 per cent of all under-five deaths occur in the first 28 days of life, increasing from 37 per cent in Every region of the world is experiencing an increase in the proportion of under-five deaths occurring in
the neonatal period. In four regions, South Asia, East Asia and the Pacific, Latin America and the Caribbean, and the Middle East and North Africa – half or more of all under-five deaths are now concentrated in the first 28 days
of life.

3. Human Milk: The Ultimate Lifesaving Medicine
Over 820,000 children’s lives could be saved annually with increased breastfeeding rates
Including 500,000 neonatal deaths annually
Nearly 13 percent reduction in all under-5 child deaths
Lancet Breastfeeding Series, January 2016

4. When mother’s own milk is not available…
Are ew asking the right questions?
When mother’s milk is not available? How are indicating that this is a need? How are we measuring this key period for these vulnerable infants?

5. What does WHO recommend?
For low-birthweight or preterm, infants who do not have access to their mother’s own milk, WHO recommends donor human milk (DHM) from a human milk bank (HMB) as the best alternative2

6. Critical lack of human milk banks in the region

7. What is a human milk bank?
A human milk bank is a service established to recruit breast milk donors, collect donated milk, and then process, screen, store, and distribute the milk to meet infants’ specific needs for optimal health.
The mission of a human milk bank is to promote and support breastfeeding by providing to the safe, high quality donor milk to fill a gap for those who need mothers’ own milk but cannot receive it.

8. The Mother-Baby Friendly Initiative Plus Model: Integrating Human Milk Banking into Newborn Care

9. What does the evidence say?

10. Is there risk of HIV transmission?
Orloff et al
Human milk was inoculated with HIV-1 or with HIV-1-infected cells. The inoculated milk was Holder pasteurized.
Pasteurization effectively inactivated the infectivity of both cell-free HIV-1 and HIV-1-infected cells.
No virus was recovered after the process, even after repeated subculturing
Ballard et al
Milk samples were spiked with 1 x 10 (8) copies/mL of clade C HIV-1 and treated with flash heat treatment or holder pasteurization.
HIV reverse transcriptase (RT) activity was measured before and after heating
Both methods eliminated bacteria
Orloff SL, Wallingford JC, McDougal JS. Inactivation of human immunodeficiency virus type I in human milk: effects of intrinsic factors in human milk and of pasteurization. J Hum Lact. 1993;9(1):13-7
Israel-Ballard K, et al. Viral, nutritional, and bacterial safety of flash-heated and pasteurized breast milk to prevent mother-to-child transmission of HIV in resource-poor countries: a pilot study. J Acquir Immune Defic Syndr. 2005;40(2):

11. What about transmission of other viruses and bacteria?
A systematic review of 26 articles investigating pasteurization methods and microbiological content.
Holder pasteurization and other types of human milk treatments inactivated CMV, E.Coli, Staph aureus, Listeria, Bacillus among others.
Peila, Chiara et al. Human Milk Processing: A Systematic Review of Innovative Techniques to Ensure the Safety and Quality of Donor Milk Journal of Pediatric Gastroenterology and Nutrition64(3): , March 2017.

12. What about the immunological activity of donor milk after freezing and pasteurizing?
100% activity retained for monoglycerides, free fatty acids, linoleic acid
Slightly decreased activity for IgA and sIgA, IgG, lactoferrin and lysozyme
No activity for IgM, bile salt activiated and lipoprotein lipase
Douglas B. Tully, PhD, Frances Jones, RN, BScN, IBCLC, and Mary Rose Tully, MPH. Donor Milk: What’s in It and What’s Not. J Hum Lact (17)2, 2001
Lepri L, Del Bubba M, Maggini R, Donzelli GP, Galvan P. Effect of pasteurization and storage on some components of pooled human milk. J Chromatogr B Biomed Sci Appl. 1997;704:1-10.

13. How about the nutritional content of donor milk after freezing and pasteurizing?
Vitamin content remained largely intact with the exception of Vit C and E that declined
Lactoferrin and Lysozyme concentrations also declined
Israel-Ballard K, et al. Viral, nutritional, and bacterial safety of flash-heated and pasteurized breast milk to prevent mother-to-child transmission of HIV in resource-poor countries: a pilot study. J Acquir Immune Defic Syndr. 2005;40(2):

14. Why not just use formula?
Meta-analysis of data from six trials found a statistically significant higher incidence of NEC in the formula-fed group: typical RR 2.77 (95% CI 1.40 to 5.46); RD 0.04 (95% CI 0.02 to 0.07)
3 trials - statistically significant higher incidence of feeding intolerance in the formula-fed group: typical RR (95% CI 1.17 to 20.70); RD 0.10 (95% CI 0.01, 0.19)
Time to full enteral feeds mean - 9 days vs 23 RR 0.33 (0.16 to 0.66) p =
Reduced risk of late-onset sepsis in vulnerable, LBW infants by 19% in first 28 days compared to formula
Quigley M, McGuire W. Formula versus donor breastmilk for feeding preterm or low birth weight infants. Cochrane Database of Systematic Reviews 2014, Issue 4. Art. No.: CD
Simmer K, Hartmann B. The knowns and unknowns of human milk banking. Early Human Development. 2009:

15. Is it cost-effective?
Cost of providing DHM to preterm infants is mitigated by a reduced risk of complications and shorter length of stay in NICU
Estimated savings to NICU for every dollar spent on DHM: ~US$11
In Brazil, the national HMB network has saved $540 million in health care costs annually
Wight NE. Donor human milk for preterm infants. Journal of Perinatology. 2001;21:249–254.
Ganapathy V, Hay JW, Kim JH. Costs of necrotizing enterocolitis and cost-effectiveness of exclusively human milk-based products in feeding extremely premature infants. Breastfeeding Medicine. 2012;7(1):29–37.
Schanler RJ, Shulman RJ, Lau C. Feeding strategies for premature infants: beneficial outcomes of feeding human milk versus preterm formula. Pediatrics. 1999;103(6):1150–1157.

16. Other notable effects
After opening the human milk bank, enteral feedings began 31 hr earlier (p < 0.001)
Feeds of 100 ml/kg/day were achieved 59.5 h before (p < 0.001) and 150 ml/kg/day 52 h before (p = 0.002)
There was a higher consumption of own mother’s milk during the hospital stay, and a higher rate of exclusive breastfeeding at hospital discharge (54% vs 40%).
The percentage of infants who are exclusively breastfed at discharge is 7.6% higher in NICUs with an HMB
S. Vázquez-Román et al Clinical impact of opening a human milk bank in a neonatal unit. An Pediatr (Barc). 2014;81(3):
Arslanoglu S, Moro GE, Bellù R, et al. Presence of human milk bank is associated with elevated rate of exclusive breastfeeding in VLBW infants. Journal of Perinatal Medicine. 2013;41(2):129–131.

17. Summary
For low-birthweight or preterm infants who do not have access to their mother’s own milk, donor human milk from a human milk bank is recommended as the best alternative
Pasteurization inactivates viruses and bacteria including HIV and CMV
In comparison to formula, DHM is associated with shorter time to full enteral feeds, lower incidence of feeding intolerance, lower incidence of NEC and lower risk of late onset sepsis
Processing largely retains immunological and nutritional content