Risks of the unregulated market in human breast milkBMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h1485 (Published 24 March 2015) Cite this as: BMJ 2015;350:h1485
All rapid responses
Thank you for the comments and feedback. The authors certainly agree that there are complex ethical, legal, and economic, aspects to the growing trade in infant feeding and infant feeding products. While these topics were not the focus of this piece, the authors acknowledge that these aspects require much expansion and research, which we note is being undertaken by colleagues (see references below). We note that our piece was constrained by the word length and plain English requirements of the BMJ; complex technical discussion of the desirability of the medicalisation and commercialisation of breast milk were not possible on this occasion.
As to comments about our sources, the authors believe the Ohio studies and other studies including studies on unpasteurised, raw milks (see reference list below), suggest that, like infant formula, warnings about risks need to be made to assist caregivers in optimising the safety of infant feeding. While we could not fully survey the aspects of all other forms of infant feeding in a 900wd piece with a limited number of reference requirement, we acknowledge elsewhere and in all related media that all forms of infant feeding involve some risk, and the task is about minimising risk so as to optimise infant health.
Many responses and comments on our piece suggest a lack of knowledge about the EU and UK environment. To clarify for such international readers, infant formula is heavily regulated. In the UK, caregivers receive multiple warnings at various stages (e.g. in hospital, on packaging, and online) about the risks and benefits of formula feeding, including routine statements that breast feeding is optimal for infant health. These statements also include information about optimal preparation conditions for formula feeding, specifically using water that is 70-90 degrees Celsius be used in mix-at-home products, and that good hygiene practices be engaged around bottles and length of use once the product is opened or prepared. Such information is prolifically available and certainly no caregiver purchasing formula or researching it online from the UK can avoid such notification and information.
The same cannot be said with regards to proper collection, handling and processing of another woman's breast milk being purchased online, where little to no information on safety and proper care information is required to be provided in the UK, even on for-profit commercial websites. This is despite regular pamphlet and health visitor advice to caregivers of infants and young people on feeding, including breastfeeding and weaning advice.
While we agree that contamination of infant formulas in the US is a serious point for regulators, our research focused on online milk sale as particular and deeply concerning. As such, we recommend that regulators and professional organisations in the UK should, like the FDA has in the USA, issue clear statements on the dangers of this industry accessible by all practitioners and caregivers, with such information being required to be routinely provided to caregivers by professionals and all commercial sites offering services in the UK. A click-agreement similar to that used around formula could be the subject of further research. The beneficiaries of such information would no doubt be the infants who receive safe nutrition and optimal feeding according to sound medical advice and scientific research.
The authors note that milk-sharing-- a non-market (e.g. donation-based), peer-to-peer practice between caregivers and mothers-- was not the focus of our piece. We also encourage further research and information on this practice, which is outside NHS provision and is also infrequently discussed in government-sponsored caregiver education. There is expansive information and support of breastfeeding as a matter of EU, national, professional and local-level requirement across the UK, but little advice on sharing and use of another woman's milk. This certainly should be a topic of further discussion, but was outside the scope of our discussion on this occasion.
On the topic of donated milk, we agree with the rapid responses that milk banks in the UK, particularly in Northern Ireland, are in low stock. We know one of the rapid response authors intended to suggest our purpose was to drive up supply in such banks and to de-legitimise other sources of feeding. We note that such milk banks operate according to NICE guidance to optimise infant feeding in the UK, alongside clear statements that breast milk is optimal for infant nutrition. Such NICE guidance is based on clear clinical and nutritional research. Certainly, women with an excess of milk will be well-received by these banks, who offer medically ill and pre-term infants essential life-saving milk. While we understand rapid responses and other responses published elsewhere wish to add an economic aspect to our discussion of milk banks, in the UK such banks are dedicated to safe, kind and effective infant feeding under the auspices of the NHS.
For those experiencing feeding difficulties who are not eligible for such banks, a range of NHS services are offered to assist in the making of safe feeding choices, including medical and lactation consultation (which may aid, amongst other things, mothers in naturally or pharmacologically increase supply), as well as around choosing infant formula should this be regarded as optimal for the infant. We advise all UK-based caregivers to turn to such advice rather than relying on online commercial websites selling milk, which pose unique dangers caregivers cannot themselves address at home.
The primary author would also like to note that other online responses have 'red penned' the op-ed to read as a US-based piece and expanded the language to include milk sharing, providing a review of our addressing of this form of exchange. While some interesting feedback has been gleaned from such responses, it is worth noting that this article was:
1) primarily directed at an audience that is UK-based, accessible to other jurisdictions where similar emergent markets are establishing themselves alongside public healthcare systems; and
2) directed at dealing with the online ‘market’/‘trade', both words reviewers deemed sufficient to direct the reader that we were solely focused on aspects of commercialised online milk exchange by reviewers who felt excessive definition was too lengthy and redundant.
The BMJ has strict word and manuscript preparation requirements, and we also responded to two blind peer reviews. The reviewers request to delete complex or redundant words and phrases was observed to improve the readability and length of the piece. Also, the choice to refer to not refer to HMBANA milk banks is a product of the British nature of this publication and the choice not to adopt an Ameri-centric focus; a choice all authors of such short pieces must make in meeting length requirements and reviewer suggestions. Also, the choice of language like 'up-to' was to reflect some milk banks may not charge or may charge scaled amounts. Similarly, the failure of this piece to refer to milk sharing was based on reviewer suggestions that such discussion was off-topic due to our focus on the online market. Those interested in milk sharing should consider also the references below, which expand more fully on this and other exchange-based milk practices.
Responses that focus on our failure to suggest further support for mothers in breastfeed ignore both our acknowledgement that we encourage breastfeeding routinely and the expansive provision the UK government and NHS make in supporting breastfeeding and actively promoting it as optimal infant nutrition. Certainly, a discussion of the online trade in milk is not a 'red herring' as some have suggested, but instead an essential piece of information caregivers should consider alongside other feeding choices; choices that at present are the subject of far greater discussion and information provision in the NHS than the online trade. We are not seeking resources be moved from breastfeeding, nor do we seek to remove support for breastfeeding. We simply advocate nationalised, professional and service-level promotion of information, regulation and professional guidance that seeks to address dangerous and unsafe practices emerging online, and to promote safe and effective infant feeding in the UK and hopefully beyond.
Cassidy, T. (2012). Mothers, Milk and Money: Maternal Corporeal Generosity, Social Psychological Trust, and Value in Human Milk Exchange. Journal of the Motherhood Initiative for Research and Community Involvement, 3(1).
David, S. (2011). Legal Commentary on the Internet Sale of Human Milk. Public Health Reports, 126(2),p.165.
Fentiman, L. (2009). Marketing Mothers' Milk: The Commodification of Breastfeeding the New Markets for Breast Milk and Infant Formula. Nev. LJ, 10, p.29.
Geraghty, S., Heier, J. and Rasmussen, K. (2011). Got milk? Sharing human milk via the Internet. Public Health Reports, 126(2), p.161.
Geraghty, S., McNamara, K., Dillon, C., Hogan, J., Kwiek, J. and Keim, S. (2013). Buying Human Milk Via the Internet: Just a Click Away. Breastfeeding Medicine, 8(6), pp.474--478.
Gribble, K. D. (2014). “I'm Happy to Be Able to Help:” Why Women Donate Milk to a Peer via Internet-Based Milk Sharing Networks. Breastfeeding Medicine, 9(5), 251-256.
Keim, S., McNamara, K., Jayadeva, C., Braun, A., Dillon, C. and Geraghty, S. (2013a). Breast milk sharing via the Internet: the practice and health and safety considerations. Maternal and child health journal, pp.1--9.
Keim, S., Hogan, J., McNamara, K., Gudimetla, V., Dillon, C., Kwiek, J. and Geraghty, S. (2013b). Microbial contamination of human milk purchased via the Internet. Pediatrics, 132(5), pp.1227--1235.
Martino, K., & Spatz, D. (2014). Informal Milk Sharing: What Nurses Need to Know. MCN: The American Journal of Maternal/Child Nursing, 39(6), 369-374.
O’Connor, D. L., Ewaschuk, J. B., & Unger, S. (2015). CURRENT OPINION Human milk pasteurization: benefits and risks. Curr Opin Clin Nutr Metab Care, 18.
Palmquist, Aunchalee (In Press, 2015) “Demedicalizing Breastmilk: The discourses, practices, and identities of informal milk sharing,” In, Tanya Cassidy and Abdullahi El-Tom, Editors, Ethnographies of Breastfeeding: Cultural Contexts and Confrontations.” Bloomsbury Academic, Ch.2.
Perrin, M. T., Goodell, L. S., Allen, J. C., & Fogleman, A. (2014). A mixed-methods observational study of human milk sharing communities on Facebook. Breastfeeding Medicine, 9(3), 128-134.
Silvestre, D., Lopez, M., March, L., Plaza, A. and Martinez-Costa, C. (2005). Bactericidal activity of human milk: stability during storage. British Journal of Biomedical Science, 63(2), pp.59--62.
Smith, J. (2013). “Lost Milk?” Counting the Economic Value of Breast Milk in Gross Domestic Product. Journal of Human Lactation, 29(4), pp.537--546.
St-Onge, M., Chaudhry, S., & Koren, G. (2015). Donated breast milk stored in banks versus breast milk purchased online. Canadian Family Physician, 61(2), 143-146.
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Competing interests: No competing interests
Increasingly parents are aware of the importance of breastfeeding and the risks of formula feeding and so desire that their infants be fed only breastmilk. However, options are limited where maternal breastfeeding is insufficient or not possible. Banked donor milk is not available in most instances. As a result, some parents seek milk from another mother for their baby.
In their BMJ editorial, Steele, Martyn and Foell 1 suggests that it is common for parents to buy milk online and they warn against this as a dangerous practice. While we agree that there are perils to the commericalisation of human milk, the sale and purchase of human milk remains uncommon. It appears that many are attempting to sell milk online, but few are buying 2.
In general, parents seeking milk for their infants reject milk providers who want payment and instead seek altruistically motivated donors (Palmquist 2014). Furthermore, they vet their donors carefully. They ask questions about lifestyle and health, get to know their donor, obtain medical test results, sometimes they heat treat milk, and they reject milk from donors who do not meet their requirements 3. Shipping of breastmilk is unusual, most recipients meet their donor in person in order to receive milk (Palmquist and Doehler, under review).
This brings us back to the discussion of bacterial contaminated milk by Steele et al. An examination of the research cited in the editorial reveals that the circumstances under which milk was found to be contaminated were extreme. This milk was bought online, in anonymous transactions, without any screening except to exclude sellers who were interested in the wellbeing of the recipient, and shipped to a post office box without any care instructions 4. It is not at unsurprising that there would be problems with this sort of milk. It would be surprising indeed however, for real parents to obtain milk in this way.
The perils of sale in other human tissues, like blood, have been previously revealed and have demonstrated that the profit motive undermines safety to a significant degree in a variety of ways 5 6. There are additional issues of ethical concern, related to the potential for exploitation of milk producers and consumers when human milk carries a price tag. These risks are present wherever milk is sold, not only via informal online sales, but also when for-profit companies get involved 7. It may be that the regulation of human milk sales and even the prohibition of the sale of human milk, as a human tissue, is appropriate.
Health care providers are well placed to help parents needing additional milk for their infant to make informed decisions 8. A growing evidence base regarding milk sharing practices, risk perception, and screening behaviors will only enhance health care providers’ ability to provide parents with this information and support. However, in order to do this, health care providers need to be able to distinguish between open vs. anonymous milk sharing and between milk sales and donations so as to delineate the relative risks of each. Public commentary on milk exchanges, should make clear these distinction and avoid promoting fear so that confusion is avoided and dialogue is encouraged between parents and health professionals on this important issue.
1. Steele S, Martyn J, Foell J. Risks of the unregulated market in human breast milk, 2015; 350:h1485.
2. Keim SA, McNamara KA, Jayadeva CM, Braun AC, Dillon CE, Geraghty SR. Breast milk sharing via the Internet: The practice and health and safety considerations. Maternal and Child Health Journal 2013;18(6):1471-1479.
3. Gribble KD. Perception and management of risk in Internet-based peer-to-peer milk-sharing. Early Child Development and Care 2013;184(1):84-98.
4. Keim SA, Hogan JS, McNamara KA, Gudimetla V, Dillon CE, Kwiek JJ, et al. Microbial contamination of human milk purchased via the Internet. Pediatrics 2013; 132(5);e1227-e1235.
5. Titmuss RM. The Gift Relationship: From Human Blood to Social Policy. New York: New Press, 1997.
6. Swanson K. Banking on the Body: The Market in Blood, Milk, and Sperm in Modern America. Cambridge, MA: Harvard University Press, 2014.
7. Smith JP. Markets, breastfeeding and trade in mothers' milk. International Breastfeeding Journal 2015;10(9).
8. Gribble KD. Biomedical ethics and peer-to-peer milk sharing. Clinical Lactation 2012;3(3):109-12.
Competing interests: No competing interests
The article highlights an important issue: safety of breast milk sold in the internet. However, the article’s message is not clear at some points. Authors say:”“Although breast milk holds many known benefits, seeking out another’s milk rather than turning to instant formula poses risks.”. This implies that instant formula is less risky than another mother’s milk. First of all, this claim is not supported with data. Infant formula poses several health risks in short and long term.
Moreover, this statement is too general and might be perceived to cover all sorts of using other mothers’ milk, including not only commercial sales of human milk, but also established milk banks and informal milk sharing among mothers. After this sentence, the WHO guidance is stated: “When breast milk is screened and treated appropriately, as the World Health Organization states, it remains second to a mother’s own milk as best for infant feeding.” which clearly says that 'breast is the best' and if it is not available, second best is appropriately treated milk of other mothers. So, the first sentence that implies that all forms of using other mothers’ milk is risky is conflicting with the WHO recommendation.
When referring to data, the article is articulated carefuly, to refer only to trading of breast milk in the internet. However, other statements in the article, such as I quoted above, generalise the issue to all forms of using other mothers’ milk, but it is not supported with data.
Secondly, the article limits the issue in the form of a dichotomy: infant formula vs. breast milk sold in the internet. However, there are other ways of informal milk sharing that has been going on all around the world. By the word ‘informal’, I mean any sharing without the mediation of an established milk bank. Several mothers who find each other in the internet and live in the same city share their milk, without any costs. This means, parents themselves transport the milk door-to-door, or even further, fridge-to-fridge, which minimises all the risks stated in the cited articles about poor standards of transportation and bacterial colonization. This form of milk sharing is usually done without any payment. The mothers meet each other face-to-face and the donor mother, who is also breastfeeding her own child, donates the milk that she would have given to her child. So, she doesn’t continue lactating as a way to earn money. This is very much different than sales of breast milk in the internet in terms of its risk profile.
Despite my concerns on generalised statements as laid out above, I agree with the authors that uncontrolled sales of breastmilk in the internet might have risks. Therefore, possible risks and benefits must be investigated by health authorities. Moreover, guidance must be provided to improve the conditions of different forms of milk sharing.
Competing interests: I write blog articles in Turkish on breastfeeding and help mothers over the internet about the problems they encounter in the course of breastfeeding, on a voluntary basis (unpaid and have no financial interests).
In the past decade there has been in the USA a growing interest in milk sharing over the internet. At the same time there has been a growth in the number of not-for profit milk banks as well as two companies that collect human milk for profit and one is selling a human milk-based infant formula to premature infants. There has also been an explosive growth in US patents and patent applications on various human milk components. Yet I fail to see that this editorial understands the complexity of what is happening in the USA and world-wide.
The studies used by the authors as proof that internet milk sharing is risky because of contamination are based on studies done from Cincinnati Children's Hospital of Ohio. The results of at least one of these studies have been questioned. (Stuebe A, Online mik sales, beyond "buyer beware." Academy of Breastfeed Medicine blog, October 21, 2013) And one of the researchers in many of these studies helped found and is involved with the Mother's Milk Bank of Ohio(SR Geraghty) In the US non-profit milk banks have complained since the 1990s about internet milk sharing. In the past few years they have also stated that they are witnessing a shortage of donor milk. Is the need for a regulated market in human milk about risks of contamination? Or is this need about controlling a resource--human milk? Who benefits from such regulation?
The authors of this editorial state, "Although breast milk holds many known benefits, seeking out another's milk rather than turning to instant formula poses risks." Is infant (instant?) formula without risk of contamination? We have had over the years in the USA infants who have died or been damaged by contaminated infant formula. We now know in the USA that most infant formula is contaminated with genetically engineered organisms. Should the answer to internet milk sharing/selling be regulation in which the only choice parents have is donor milk purchased through milk banks or infant formula purchased at a store or online? Is this issue really about safety or about economics?
Competing interests: No competing interests