International Perspectives

Human Milk Banking: An Indian Experience

Sushma Nangia, MD, DM (Neonatology),* Ruchika Chugh Sachdeva, MS (Nutrition),† Vandana Sabharwal, MS, PhD (Nutrition)‡ *Department of Neonatology, Lady Hardinge Medical College & Kalawati Saran Children’s Hospital, New Delhi, India †Maternal, Newborn, Child Health and Nutrition, PATH India, New Delhi, India ‡Institute of Home Economics, Delhi University, New Delhi, India

Education Gaps

1. There is a scarcity of systematic data on human milk banking practices in India. 2. The role of policy and technical leaders in promoting human milk banking as part of an integrated approach in optimizing neonatal health needs to be understood.

Abstract

As part of integrated newborn care, human milk banks can reduce death and illness as well as lower health-care costs for infants born prematurely, especially with birthweights less than 1,500 g, and for infants born in resource-limited settings without access to their mother’s milk. Promotion of human milk banks is of special significance in India which has the highest burden of such infants. About 50 milk banks are insufficient to meet the needs of vulnerable infants. The government of India has acknowledged the role that human milk banking can play in reducing neonatal mortality and morbidity, and launched the “National Guidelines on Lactation Management Centers in Public Health Facilities” in 2017 with a vision to make breast milk universally available for all infants. The government is now working on an implementation strategy to scale up the lactation management center model AUTHOR DISCLOSURE Drs Nangia and (promotion of breastfeeding, kangaroo mother care, and donor human milk) Sabharwal and Ms Sachdeva have disclosed no financial relationships relevant to this for all newborn care units and delivery centers in the country. However, for article. This commentary does not contain a effective expansion, it will be important to ensure improved government discussion of an unapproved/investigative use of a commercial product/device. ownership, mandate availability of standard operating procedures at all facilities, stringent systems of quality control, standardized accreditation, and ABBREVIATIONS a robust monitoring system. Local evidence on the effectiveness of the CLMC Comprehensive Lactation Management Center comprehensive lactation management center (CLMC) model and knowledge, LMU lactation management unit practices, and perceptions of human milk banking are limited. There is a need LSU lactation support unit for rigorous implementation, process research, and technology innovation, ’ MAA mother s absolute affection along with a robust regulatory framework to prevent commercialization. In MOM mother’s own milk fl MBFIþ Mother Baby Friendly Initiative Plus addition, attitude changes of mothers, maternal in uencers, and health-care NMR neonatal mortality rate providers are all essential to successfully expand the CLMC model.

Vol. 19 No. 4 APRIL 2018 e201 Downloaded from http://neoreviews.aappublications.org/ by guest on April 2, 2018 Objectives After completing this article, readers should be able to:

1. Describe how prioritizing an integrated approach in human milk banking can save lives in India. 2. Recognize the salient features of the national guidelines on human milk banking along with the human milk banking environment in India. 3. Outline key initiatives to be addressed for effective scaling up of human milk banking in India.

THE POWER OF HUMAN MILK studies demonstrate the positive effect of donor human milk on vulnerable infants as compared with formula, such Breastfeeding is the most natural, inexpensive, environment- as reduced risk of sepsis and necrotizing enterocolitis, greater friendly, and easily accessible method to provide all children, feeding tolerance, reduced length of stay in NICUs, and sub- rich or poor, with the healthiest start to life and ensures that all stantial cost savings for resource-strapped public health sys- children survive and thrive. Breast milk offers the ideal source tems (Table 1). (8)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22) fi of nutrition for the rst 6 months after birth, and may remain (23)(24)(25)(26) ’ fi a part of an infant s diet for the rst 2 years of age and beyond. A recent study found that if all premature infants born in (1) There is evidence that demonstrates the value of breast- the United Kingdom in 2013 were provided with mother’s feeding for both a mother and her child. Sushruta,anancient milk in the NICU, the total lifetime cost savings to the ’ Indian surgeon, has beautifully described mother smilkin National Health System would be an estimated $46.7 million “ his Samhita, One just cannot compare even water of seven (£30.1 million in the first year) as a result of improved health ’ seas with mother s milk, which is nothing but water ensur- outcomes. The total lifetime quality-adjusted life-year gain ing optimum growth, nutrition, and healthy life of hundred was calculated to be 10,594 years. There would be 238 fewer ” years. (2) deaths caused by neonatal infections and sudden infant death ’ However, many infants lack access to their mother s own syndrome, leading to a savings of approximately £153.4 ’ milk (MOM) because of issues related to the mother sillness million in lifetime productivity. (27) ’ or death, abandonment, infant s illness, inability to latch, or Providing donor human milk to vulnerable neonates delay in milk production. This lack of access to breast milk without access to MOM not only saves lives but also enhances leaves infants more vulnerable to disease, poor health, or awareness about breastfeeding and improves breastfeeding death, especially when they are born preterm, have low rates. This increase in breastfeeding rates is important birthweight, or are severely malnourished. (3)(4)(5) In such because it has the potential to prevent 820,000 “under-5” a scenario, the World Health Organization, (6) American deaths (ie, death before age 5 years), of which 87% are Academy of Pediatrics, (7) the Committee on Nutrition infants younger than 6 months of age. (28) Improving of the European Society for Pediatric Gastroenterology, breastfeeding rates worldwide is a fundamental driver to Hepatology, and Nutrition, (8) and other policy groups achieve Sustainable Development Goals by 2030. recommend donor human milk, made available through human milk banks, as the next best feeding option when HUMAN MILK BANKING: A CENTURY-OLD PRACTICE MOM is unavailable. A human milk bank screens and recruits breast milk donors; collects, processes, and screens Saving infants with the use of donor human milk through donated milk; and distributes the milk to infants in need. human milk banks is a century-old practice. Countries in As part of integrated newborn care, human milk banks North America and Europe established human milk banks reduce death and illness as well as lower health-care costs. in the early 20th century. The United Kingdom established Data exist, which support the health benefits of donor its first human milk bank in the 1930s, and Brazil in the human milk, especially for infants born prematurely, with 1940s. Today, more than 600 milk banks have been estab- birthweight less than 1,500 g, (9) and for infants born in lished in more than 50 countries. Human milk banks have resource-limited settings where a non-breastfed child’s risk been extremely successful in Brazil, its network being the of death is 6 times that of a breastfed child. (10) A myriad largest in the world with 213 milk banks and 199 collection

e202 NeoReviews Downloaded from http://neoreviews.aappublications.org/ by guest on April 2, 2018 TABLE 1. Studies Demonstrating the Impact of Donor Human Milk on Vulnerable Infants

Sepsis • Donor human milk reduced the risk of late-onset sepsis in vulnerable, low-birthweight infants by 19% in the first 28 days. (11) • Donor human milk has a greater protective effect compared with formula. (12) Necrotizing enterocolitis • Human milk feeding, whether mother’s own milk or donor human milk reduces necrotizing enterocolitis by as much as 79% when formula is avoided. (13) • Four systematic reviews across study designs and countries found that donor human milk protects preterm infants against necrotizing enterocolitis more than formula. (8)(14)(15)(16) Retinopathy of prematurity • Human milk feeding in the NICU is associated with lower rates of severe retinopathy of prematurity. (17,18) Feeding tolerance • Preterm infants fed unfortified donor human milk had greater feeding tolerance, fewer vomits, less gastric stasis, and reduced diarrhea compared with formula-fed infants. (16) Reduced length of stay in NICU • Cost of providing donor human milk to preterm infants is mitigated by a reduced risk of complications and shorter length of stay in NICU. (11)(19) • Fewer hospital readmissions for illness in the year after NICU discharge have been noted. (20) Cost saving • The percentage of infants who are exclusively breastfed at discharge is about 13% higher in NICUs with a human milk bank. (21) • A study reported saving wUS $8,167 per infant using donor human milk through shortened length of stay and reduced cases of necrotizing enterocolitis and sepsis. (19) • Estimated savings to NICU or health care plan for every dollar spent on donor human milk: wUS $11. (22) • In Brazil, the national human milk banking network saves $540 million in health care costs annually. (23) Neurodevelopmental outcomes and • Later in childhood and adulthood, preterm infants fed human milk have been shown to have lower long-term benefits rates of metabolic syndrome, (24)(25) increased white matter and brain volume, and significantly greater scores for mental, motor, and behavior ratings. (19)(26)

centers. The Brazilian Network of Human Milk Banking has India has made considerable progress over the last 2 decades successfully demonstrated the effectiveness of a government- in the area of maternal and child health through innovative and supported, nationalized, integrated human milk bank pro- comprehensive health packages that cover the spectrum of gram that includes breastfeeding promotion, lactation life cycle stages. However, newborns have missed out on the support, and provision of donor milk, all of which have attention. Even though the under-5 mortality rate decreased by contributed to achieving a single-digit neonatal and infant 42%, from 74 (in 2005–06)to43(in2015)per1,000livebirths, mortality rate. Brazil’s integrated human milk banking pro- in the same period, neonatal mortality rate (NMR) decreased gram saves the country an estimated $540 million annually from 37 to 25 per 1,000 live births, accounting for a decrease of through improved neonatal health outcomes. (29) only 32%. (31)(32) This decline in NMR is laudable but it has to increase to effectively achieve sustainable development goals, PRIORITIZING AN INTEGRATED APPROACH FOR which aim to eliminate preventable deaths of children less than HUMAN MILK BANKING IN INDIA 5 years of age, with all countries aiming to decrease the NMR to aslowas12per1,000livebirths.(33) India faces its own unique challenges. The country is the About 75% of premature infants can be saved with highest contributor to the global birth cohort, neonatal feasible and cost-effective interventions. These include kan- mortality rate, and birth of vulnerable infants, that is, infants garoo mother care; adequate neonatal resuscitation; pre- born prematurely and with low birthweight. Of the 27 vention, detection, and treatment of neonatal infections; and million infants born in India annually, 30% are born with breastfeeding. (34) Of these, breastfeeding has been iden- low birthweight (ie, weighing <2,500 g), and 40% of all low- tified as the single most powerful intervention, with the birthweight infants (estimated at 3.5 million infants), are potential to prevent 0.16 million under-5 deaths in India. born preterm (Fig 1). (30) Of the 0.76 million infants who (28) Yet, breastfeeding rates remain low, with only 41.6% of die in the neonatal period, prematurity is the major cause, infants being initiated into breastfeeding within 1 hour of accounting for 35% of all deaths, followed by infection, birth and 54.9% of infants exclusively breastfed until 6 accounting for another 33%. (30) months of age. (35)

Vol. 19 No. 4 APRIL 2018 e203 Downloaded from http://neoreviews.aappublications.org/ by guest on April 2, 2018 Breastfeeding has a pertinent and important role to play Municipal Medical College and General Hospital, Mumbai, in improving the status of neonatal health in India. This India. The milk bank was started after realizing the acute emphasizes the need to universalize access to human milk need to save sick infants in hospitals. It soon became as an integral component in the country’s health-care sys- sustainable as mothers who had delivered at the hospital tem, especially in all newborn units that provide care to sick and donated milk to the milk bank returned for follow-up infants. Providing human milk through human milk care. (37) Despite the successful establishment of this bank, banks can work only if it is a part of the larger objective other hospitals were not encouraged to take up this venture of promoting breastfeeding. There is a need to link human and this remained the only human milk bank in the country milk banking systems with breastfeeding and kangaroo until the year 2005. From 2005 to 2015, only 22 human milk mother care by establishing high-quality systems, sharing banks were established, but in the past 2 years, this number global best practices, and facilitating capacity building. An has more than doubled. There are currently about 50 milk integrated intervention will not only assist in feeding human banks in India, which are still inadequate to meet the massive milk to preterm and low-birthweight infants, but will also demand for donor human milk (Fig 3). To put this in per- increase breastfeeding rates in the country. Previous experi- spective, the United Kingdom has 770,000 births each year ence shows that human milk banks thrive in countries where and 16 operational milk banks, whereas India has 27 million they are protected, promoted, and endorsed as a critical com- births each year and only 50 operational milk banks. ponent of breastfeeding and newborn care policies. (29) Historically, implementation of effective regulated, coun- Based on its existing toolkit on the establishment of try-specific, human milk banks have been slow to develop in human milk banks, “Strengthening Human Milk Banking: India. Initially, human milk banks were concentrated in the A Global Implementation Framework,”(36) PATH has western belt of the country because the first human milk proposed the “Mother Baby Friendly Initiative Plus” bank was established in this region, and the majority of milk (MBFIþ) model in which human milk banks collect, pro- banks were modeled on this first one. The development of cess, and store donor human milk while serving as centers milk banks has met with several challenges including that provide lactation and kangaroo mother care support. inadequate collaboration between obstetricians and pedia- (29) Because successful breastfeeding often requires tricians, lack of lactation counselors, and limited awareness. support from the family and community, the model also (37) There are also gaps in providing able leadership for positions human milk banks to work with and engage sharing best practices and robust procedures. However, the local communities. These banks promote the significance changing landscape has facilitated an expansion in human of breastfeeding and milk donation, build awareness about milk banks in some parts of the country. the value of human milk, and collaborate with employers and other leaders to create an enabling and supportive INDIA-SPECIFIC STUDIES ON HUMAN MILK BANKING environment for breastfeeding and milk donation. (36) The MBFIþ model is deliberately intended to be altered by A recent study conducted to understand current practices, each country to fit its unique needs. Similarly, the model has processes, infrastructure, personnel structure, and funding been adapted to suit India’s public health structure (Fig 2). mechanisms in human milk banks with minimum 1 year of functioning (n¼16) revealed that standardization of HUMAN MILK BANKING LANDSCAPE IN INDIA processes as well as data capturing and reporting were urgently needed. (38) Only 25% of the study sites pooled In India, voluntary donation of human milk in the form of milk under laminar airflow. Sixty-two percent of the facilities wet nursing has been an integral part of its tradition. used steel containers for milk pasteurization and storage, Mythological anecdotes tell tales of Yashoda, who was a wet which is unique to India. Because steel is widely used in nurse (human milk donor) to Lord Krishna. In the 18th homes and laboratories and has good conductivity, it results century, wet nursing was widely practiced for offspring of in faster heating and cooling cycles. This helps preserve mothers born into nobility who refused to breastfeed their milk nutrients better, especially its sensitive immunologic infants to preserve their beauty and figure. Later, the practice components, because the duration of exposure to extremes declined because of a fear of transfer of infections and of temperature is curtailed. Steel can be easily cleaned and diseases such as syphilis. Much later, the concept of human sterilized by exposure to dry heat in a normal oven, there- milk banks was introduced. fore, it has been an obvious choice of milk banks in India. In Asia, the first human milk bank was established Only 50% of milk banks had dedicated full-time technicians. in 1989 by Dr Armida Fernandez in Lokmanya Tilak In the remaining milk banks, lactation counselors and other

e204 NeoReviews Downloaded from http://neoreviews.aappublications.org/ by guest on April 2, 2018 Figure 1. Overview of newborn health in India compared to global statistics. staff managed the processes. Only 31% of milk banks had Only in-facility dispensation of donor human milk is 3 or more dedicated lactation counseling staff; thus, the promoted and once the infant goes home, there is no source shortage of staff has been a stumbling block. Most of the of continuing human milk feeding if the mother cannot feed milk banks pooled donor milk from multiple mothers. All her child. (38) the facilities used the Holder method of pasteurization. Nearly 85% of milk banks in India have been established by Processed donor human milk was used within a week or nongovernment organizations, and only a handful had been fortnight because of high demand in most of the sites. Milk supported by the government. (38) However, within the last collection was between 3 and 6 L every day in most of the 2 years nearly 50% of milk banks have been supported by the facilities. The majority of milk banks reported a significant state governments. Rajasthan, one of the states with a high demand-supply gap. Hence, as a step to help mitigate the neonatal mortality rate, has supported the setting up of 10 milk demand, select sites have recently developed satellite milk banks during the last year. Similarly, the state government of collection centers. The need to discard samples because of Tamil Nadu has supported setting up 7 milk banks. The recur- the presence of microbes after pasteurization was less than ring cost of most milk banks is managed through hospital funds. 5% at most study sites. (38) Various socioeconomic factors influence maternal moti- Milk is predominantly collected at the facility level with vation and willingness to donate breast milk. Katke and one-third of the sites collecting milk from camps and homes Saraogi reported that women at either end of the reproduc- as well. Donor milk collection in India is mainly from tive age spectrum and women with higher parity require mothers of preterm infants, hospitalized mothers after more motivation to donate breast milk. Furthermore, delivery, and mothers who visit pediatric clinics for pediatric milk donation can be promoted in India by teaching women immunizations. These mothers are mostly cross-sectional about the benefits of donor milk. (39) A recent study sur- donors. Longitudinal donation is not yet practiced in India. veyed mothers and influencers (fathers and grandmothers) Even home-based collection of milk is not common and very about barriers to breastfeeding, kangaroo mother care, and few hospitals promote it. (38) Education for safe collection is providing donor human milk to preterm and sick neonates in imperative for home-based collection because of the poten- India. (40) This study found limited awareness about human tial risks of voltage fluctuations and electricity failures. milk banks among mothers and influencers. Parents were

Vol. 19 No. 4 APRIL 2018 e205 Downloaded from http://neoreviews.aappublications.org/ by guest on April 2, 2018 Figure 2. Mother Baby Friendly Initiative Plus model adapted for India’s health structure. (Adapted from reference 36.)

supportive about donating milk once they learned that it was The government of India highlighted the need for formu- life-saving and did not compromise the supply to their own lating operational guidelines with robust protocols and empha- infant. However, some parents had safety concerns about the sis on implementation strategy, quality control mechanisms, use of donor human milk and were not aware of milk banking monitoring, and accreditation. The Ministry of Health and processes. Most grandmothers were not comfortable with Family Welfare took this initiative in 2014 and formed a group having their daughters/daughters-in-law donate milk or hav- composed of human milk bank experts, neonatologists, regu- ing their grandchild receive donor milk because they felt it latory officials, and quality and public health specialists to may hinder supply for their grandchild. Most mothers shared support this effort. Subsequently, the government launched that physicians counseled them about their dietary intake the “National Guidelines on Lactation Management Centers in during antenatal care, but did not provide them with infor- Public Health Facilities” in July 2017. (42) These guidelines mation about breastfeeding. Few mothers shared the chal- are part of a program focusing on breastfeeding launched by lenges they faced with feeding their preterm and sick infants. the government of India called Mother’s Absolute Affection Mothers who practiced kangaroo mother care were aware of (MAA). MAA in Hindi, the national Indian language, means its benefits. Respondents shared that wet nursing is an old mother. The vision of the government is to make breast practice. They found wet nursing to be helpful, as the infant milk universally available for all infants by establishing receives human milk and they are assured that it is not comprehensive lactation management centers (CLMC), harmful for the infant if practiced within the family. (40) lactation management units (LMUs) and lactation support units (LSUs) at the facility level. The CLMC model is based þ ROLE OF THE GOVERNMENT IN SCALING UP HUMAN on the MBFI model (Fig 4). ’ MILK BANKING IN INDIA The model builds on India s public health system which is a 3-tier system with primary, secondary, and tertiary levels of The government of India has acknowledged the role that care. The district hospital is an essential component of the human milk banking can play in reducing neonatal mor- district health system and provides secondary level of care. tality and morbidity and held the first national consultative Every district has a hospital that is linked to health facilities meeting for formulating national guidelines on human under the district such as subdistrict hospitals, community milk banking in 2013. Subsequently, the Indian Academy health centers, primary health centers, and health subcenters. of Pediatrics formulated a set of guidelines in 2013. (41) Primary health centers are the cornerstone of rural health

e206 NeoReviews Downloaded from http://neoreviews.aappublications.org/ by guest on April 2, 2018 Figure 3. States with operational human milk banks in India. services, providing basic essential newborn care. They cater to will be set up at tertiary care facilities/medical colleges a population of around 30,000 with the help of a medical with a functional NICU and high delivery load. This would officer, pharmacist, and support staff. Community health function as a lactation support center to support breastfeed- centers, catering to a population of 120,000 people, are the ing, as well as to safely collect, process, and provide safe first level where specialists are available. They aim to provide donor human milk. Subsequently, CLMCs will be set up at secondary level care with stabilization services for newborns. First referral units are being developed by upgrading selected community health centers and subdistrict hospitals where 24-hour emergency obstetric and child health services will be provided. (43) Currently, there are 715 functional special care newborn units, mostly at district hospitals, to reduce case fatality among sick newborns and to function as training centers for teaching newborn care skills. A large number of secondary and tertiary care units responsible for newborn care are usually within larger hospitals, many even higher than the district level such as at the medical college level.

SALIENT FEATURES OF THE NATIONAL GUIDELINES

LMCs are seen as an effort to promote the natural act of breastfeeding and ensure availability of safe donor human Figure 4. Facility based lactation management at the three levels. milk for sick infants when MOM is not available. A CLMC (Reprinted from reference 42.)

Vol. 19 No. 4 APRIL 2018 e207 Downloaded from http://neoreviews.aappublications.org/ by guest on April 2, 2018 district hospitals that fulfill the prerequisites for establish- Human milk donation and dispensation will be done ing one. These units will support breastfeeding mothers, only at specialized units within the CLMC with the highest encourage kangaroo mother care, and support the forma- regard for safety and meticulous approach to ensuring tion of LMUs at first referral units/subdistrict hospitals. quality. The guidelines consist of evidence-based and These LMUs will facilitate the expression and collection of standardized technical protocols for donor screening MOM for her infant’s use. To maintain the continuum of and collection, processing, storage, and dispensation of care, LSUs will be established at all delivery points by human milk. Ensuring the quality and safety of donor forming a dedicated team of staff trained to provide round- human milk is an important component of these guide- the-clock breastfeeding support, lactation counseling, and lines. In addition, recommendations have been made to kangaroo mother care support to mothers. (42) minimize the risk of donor human milk to recipients. The The guidelines mandate informed consent by both the donor standards of quality have been stated in detail with a strong and the recipient. Donor milk will only be dispensed with a focus on hygiene and handling of milk. The guidelines physician’s prescription and is recommended to meet the short- enforce mandatory training of staff on a Hazard Analysis and long-term needs of newborns admitted in NICUs/sick Critical Control Points system, which is a management newborn care units with the following conditions: 1) pre- system designed to address food safety from production to maturity, 2) low birthweight, 3) malabsorption, and 4) feed- consumption. ing intolerance. A National Human Milk Bank has been established Donating human milk will be a completely voluntary and which will function as the national resource center to pro- nonincentivized activity, and this milk cannot be used for vide training, undertake quality audits, and ensure technical any commercial purposes. The government is working on support to establish new CLMCs and LMUs. Regional and developing a regulatory mechanism to prevent human milk zonal reference centers will be established in each geo- commercialization. graphical zone at well-performing CLMCs, to assist the

TABLE 2. Suggested Initiatives for Technical and Policy Leaders to Improve Access to Human Milk

Improve government ownership to meet recurring costs, address personnel shortages, and enhance community mobilization. Mandate availability of standard operating procedures at facilities for uniform process implementation and to ensure safety. Establish one national and few zonal reference centers to develop stringent systems for monitoring and evaluation, accreditation and quality control. Develop a strong regulatory framework and effectively implement the same to prevent commercialization. Generate local evidence on the CLMC model by undertaking research to determine knowledge, practices, and perceptions related to the establishment of CLMCs in similar community settings and to explore the multidimensional aspects in opportunities and challenges for scaling up human milk banking in India. Develop robust behavior change communication strategies related to breastfeeding, kangaroo mother care, and donor human milk targeted at mothers and influencers, starting from the antenatal period. Provide skill-based training to medical practitioners and health care providers on the CLMC model. Ensure counseling of pregnant women and lactating mothers by health-care providers and peer educators to promote early initiation of breastfeeding in the labor room. Use mother support groups to create a suitable environment for continued and sustained breastfeeding. Slowly eliminate wet nursing, an ancient and deep-rooted practice, by generating intensive awareness about its adverse effects. Establish satellite centers attached to milk banks to recruit more donors to benefit more infants. Extend the guidelines to the private sector to ensure that infants born in the private sector (about 60% rural and 70% urban areas) are also covered. (44) Gather technical and policy leaders to discuss steps to ensure access to donor human milk for all infants in need whether in the hospital or at home. Develop technologies that improve quality systems and are easy to use and cost-effective to help human milk banks run safely and effectively not only in India but other low-resource settings around the globe.

CLMC¼Comprehensive lactation management center.

e208 NeoReviews Downloaded from http://neoreviews.aappublications.org/ by guest on April 2, 2018 national resource center by serving as a technical resource for nearby CLMCs, LMUs and LSUs. (42) American Board of Pediatrics Neonatal-Perinatal Content THE WAY FORWARD Specification • Know the advantages and disadvantages of the use of donor Some noteworthy initiatives in the recent past have human milk. been the use of the “green corridor” (organ donation van) in Rajasthan to transfer milk to needy NICUs from the collection centers in record time, as well as the establish- ment of a mobile van equipped with a breast pump and a refrigerator for collecting donor milk from mothers in the References community in the state of Maharashtra. The Human Milk 1. Kramer MS, Kakuma R. The optimal duration of exclusive Banking Network of India has been established to share breastfeeding. A systematic review. Geneva, Switzerland: World Health Organization; 2001. http://www.who.int/nutrition/publications/ best practices and create awareness among health-care infantfeeding/WHO_NHD_01.08/. Accessed September 28, 2017 providers. Media engagement has also increased over 2. Sushruta Samhita, volume 4: Cikitsasthana. https://www. thepastyearandtheissueiswellcoveredacrossmultiple wisdomlib.org/hinduism/book/sushruta-samhita-volume-4- platforms. cikitsasthana. Accessed September 28, 2017. As a next step, as policy and technical leaders work toward 3. Bertino E, Giuliani F, Baricco M, et al. Benefits of donor milk in the implementing these guidelines to ensure that all infants have feeding of preterm infants. Early Hum Dev. 2013;89(suppl 2):S3–S6 access to human milk (both MOM and safe donor human milk), 4. Panczuk J, Unger S, O’Connor D, Lee SK. Human donor milk for the vulnerable infant: a Canadian perspective. Int Breastfeed J. it will be imperative that the following initiatives are taken 2014;9:4 (Table 2). 5. Global Breastfeedign Collective. Policy brief: ensuring equitable Effective scale up of human milk banking systems in access to human milk for all infants: a comprehensive approach to India has significant potential. Estimates suggest that essential newborn care. 2017. https://www.path.org/publications/ 30% to 50% of neonates admitted to the NICU and 10% to files/MNCHN_EquitableAccesstoHumanMilk_PolicyBrief.pdf. 20% of full-term infants are in need of donor human Accessed November 19, 2017 ’ milk to meet the short- or long-term lack of mother’s 6. World Health Organization, United Nations Children s Fund. Every Newborn: An Action Plan to End Preventable Deaths. Geneva, milk. Increasing access to human milk has the potential Switzerland: World Health Organization; 2014 to help approximately 5 million infants. When combined 7. Eidelman AI, Schanler RJ, Johnston M, et al; Section on with enhanced breastfeeding methods, the impact could Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. be 10-fold. (38) 2012;129(3):e827–e841 As human milk banking systems expand and strengthen, 8. Arslanoglu S, Corpeleijn W, Moro G, et al; ESPGHAN Committee this will not only have an impact on the immediate on Nutrition. Donor human milk for preterm infants: current evidence and research directions. J Pediatr Gastroenterol Nutr. health of neonates but will also have long-term positive 2013;57(4):535–542 effects. India bears the highest global burden of neo- 9. Committee on Nutrition; Section on Breastfeeding; Committee on natal births and deaths, therefore improvement in neo- Fetus and Newborn. Donor human milk for the high-risk infant: natal health indicators will help India and the world preparation, safety, and usage options in the United States. achieve their goal of reduced neonatal mortality and Pediatrics. 2017;139(1):e20163440 morbidity. 10. UNICEF. Adopting optimal feeding practices for Child Survival. http://data.unicef.org/nutrition/iycf.html#. Accessed September 24, 2017. ACKNOWLEDGMENTS 11. Simmer K, Hartmann B. The knowns and unknowns of human milk banking. Early Hum Dev. 2009;85(11):701–704 Our special gratitude and acknowledgment is extended to 12. Rønnestad A, Abrahamsen TG, Medbø S, et al. Late-onset the policy and technical experts in India who provided septicemia in a Norwegian national cohort of extremely premature insights and guidance, which formed the basis of this infants receiving very early full human milk feeding. Pediatrics. 2005;115(3):e269–e276 work. We also acknowledge the human milk banks in 13. Updegrove K. Nonprofit human milk banking in the United States. India that are dedicated toward increasing access of J Midwifery Womens Health. 2013;58(5):502–508, quiz 596 human milk to all infants by promoting breastfeeding 14. Quigley MA, Henderson G, Anthony MY, McGuire W. Formula ’ and providing safe donor human milk, and saving infant s milk versus donor breast milk for feeding preterm or low birth lives. weight infants. Cochrane Database Syst Rev. 2007; (4):CD002971

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