The milk from a human mother is the best nutrient packed food for your newborn. Mother’s milk has complex nutritional composition that is difficult to replicate. This is why exclusive breast feeding practices followed by early initiation and colostrum feeding are crucial for proper growth and development of infants. Nutrition rich breast milk cannot be substituted by prelacteal feeds. Any alternatives besides breast feeding should be sternly avoided if possible.
WHO recommends practicing exclusive breastfeeding from the very first hour of childbirth to 6 months of infancy. However, the actual rate of exclusive breastfeeding remains low in both low-income and middle-income countries like Nepal and India. Only 44% of newborns in the whole world receive breast milk within the first hour of birth. This is a far cry from WHO’s target of improving breastfeeding rates to 70% globally, intended in its 2017 report. Out of 129 countries, only 23 countries have achieved an exclusive breastfeeding target of at least 60% in infants less than six-months-old.
In Nepal, breastfeeding prevalence within the first hour of birth, colostrum feeding, breastfeeding predominantly, and prelacteal feeding was 41.8%, 83.5%, 57.2%, and 32.7% respectively. Although, most infants are given colostrum very few receive breast milk within the first hour of birth. The biological composition of human milk is very dynamic - it varies within each stage of feeding, between individual mothers, and among population clusters. The variation in the composition is influenced by environmental and maternal factors. There are also different stages of milk production. Right after the baby is born, in the initial two weeks, milk evolves through three main stages: colostrum, transitional breast milk, and mature breast milk.
Colostrum is the first milk produced by the mammary glands and is formed at the end of pregnancy and the first few days after childbirth. It is usually present in small amounts and has a thick, yellow, and sticky texture. In rare cases, the colostrum might also be thin in consistency and white or orange in colour.
It is the first line of immunological defence for babies directly ingesting Immunological factors - IgA, lactoferrin, and leukocytes from their mother’s milk to protect against harmful diseases. Other developmental factors like epidermal growth are also present in the colostrum.
Transitional Milk and colostrum share similar characteristics, but it is a phase of “ramped up” milk production to support the nutritional and developmental needs of the rapidly growing infant, naturally formed from 5 days to two weeks post-delivery.
Mature Milk is produced from four to six weeks post-delivery. Comparatively mature milk is lower in protein but high in carbohydrate and fat content. Mature milk comprises about 90% water which fulfils baby's fluid needs.
The nutritional component of human milk is derived from three sources: Nutrients synthesized in the lactocyte, dietary nutrients, and nutrients from maternal stores.
Macronutrients
The major carbohydrate, providing energy to the infants is lactose (30- 40 %). Lactose breaks down into glucose and galactose. Glucose enters the peripheral circulation and is used as a substrate for energy production, whereas galactose is absorbed via the liver and converted into glucose-1-phosphate, which is either converted into glucose or stored as liver glycogen. Brain uses both galactose and glucose for energy, and galactose particularly to produce galactolipids (cerebroside), which are essential for the baby’s developing central nervous system. Another complex carbohydrate which is the third largest component within the human milk is Human milk oligosaccharide (HMO). HMOs do not provide a major source of energy to the baby because they are not digested in the small intestine. Instead, HMOs provide an important immunological function. It acts as prebiotics promoting the intestinal growth of commensal bacteria especially Bifidobacterium longum subsp infantis and B. bifidum. HMOs also act as receptor analogues that inhibit the binding of pathogens including Rotavirus.
Proteins provide around 8% energy to the babies; however, its concentration varies accordingly. Colostrum contains 30-70g/l of protein which then falls to a stable level of 7-14g/l in mature milk. The protein present are whey, casein, and proteins linked with the membrane of the milk fat globule. Over 415 proteins have been identified in human milk, many are active and have functional roles in protecting the baby. Proteins such as β-casein are antiseptic and anti-infective in nature. Other proteins, including secretory IgA, lactoferrin, lysozyme, macrophages, and free fatty acids also act as anti-infective agents, which are essential for the preterm infant. All these protein work in symbiosis to inactivate, destroy or bind to specific microbes, preventing their attachment to mucosal surfaces.
Majority of baby’s caloric needs is provided by fat in breastmilk. Fats deliver free fatty acids and fat-soluble vitamins to the baby. The most abundant class of fat in human milk, is Triacylglycerols (>98% of total fat). Long-chain polyunsaturated fatty acids such as docosahexaenoic acid (DHA) and arachidonic acid (AA) are important because they accumulate in the membrane lipids of the brain and retina, where they promote visual and neural functions.
Micronutrients
Human milk provides fat-soluble vitamins, water-soluble vitamins, minerals, and trace minerals to the baby, all dependent on the mother’s diet. However, maternal diet is not always optimal, therefore continuing multi-vitamins during lactation is recommended most of the time.
Bioactive components
These components affect biological processes or substrates, therefore can influence body’s function, and overall health. Human milk is not only solely nutritional but contains varieties of factors with medicinal qualities that have a profound role in infant survival and health. The major functions of these bioactive components can be summarized as Immunomodulation, Cell growth and proliferation, and Energy modulation and growth.
Human milk supplies all the essential components for the growth and development of the baby; hence it is recommended as a major food source for infants up to 6 months of life and in addition to other complementary foods for at least the first 2 years. There are numerous health benefits of breastfeeding the baby:
Antibodies present in the milk helps to protect babies from various infection and improve their immune system, which is lacking in infant formulas.
Decreases the risk of having cognitive problems as well as diseases later in life.
Human milk is easily digested, hence prevents any gastrointestinal problems, which might not be the case with all infant formulas.
The cholesterol present in breast milk promotes brain growth.
It is least expensive way to feed an infant and facilitates bonding between mother and baby.
In studies performed, it has been found that the infant mortality risk decreased by 12% in breastfed as compared to non-breastfed infants. Decrease in respiratory as well as gastrointestinal infections were observed. Breast feeding not only benefits the baby, but also benefits the mother by decreasing the risk of developing certain diseases like type 2 diabetes, hypertension, ovarian cancer, and breast cancer.
Milk Bank as a Way forward
Low birth weight is one of the major challenges in maternal and infant health sector in developing as well as developed countries. Every year WHO estimates about 25 million low birth weight babies and nearly 93% of them are in developing countries with the highest incidence (27%) in southern Asia. In Nepal, the percentage of new-borns with low birth weight (< 2.5Kg) is 11% at national level and ranges from 15.9 % to 6.9 % at different provinces (DoHS, Annual Report 2073/74 (2016/17).
Majority of times LBW (low birth weight) is a consequence of Preterm birth or small size of gestational age or both and these. LBW infants are at high risk of various diseases (diabetes, heart diseases, metabolic syndrome) later on in life. Thereby the interventions to improve the low birth weight not only improves immediate health but also long-term health and well- being of the individual infant. All of these factors contribute to significant impact in the maternal and child health indicators of the country’s population.
The recommendation by WHO for low birth infants is that they need to be fed with their own mother’s milk. When mother’s milk is not available the next best alternative is donated human milk from other mothers. Formula milk should only be considered as a last resort. Formula milk is prone to higher incidence of Necrotizing entercolitis and other gut disorders and infections in comparison to donated human milk. With the joint statement of WHO and UNICEF supporting donated human milk, the international milk banking initiative was founded in 2005 and it lists 33 countries including India with milk bank programs. Yet Nepal seems to be lagging in this aspect and this is where the idea of a first ever milk bank in Nepal arises. Establishing a milk bank would encourage and motivate mothers for breast feeding.
A milk bank can be defined as a service that collects, screens, processes, and dispenses the prescribed milk donated by nursing mothers who are not biologically related to the recipient. It provides safe and high-quality donated milk to the recipient. The donors are healthy lactating mothers who willingly donate their breast milk without compromising the nutritional needs of her baby. The pasteurized milk can be prescribed on priority for preterm babies, sick babies, babies of mothers with postpartum illnesses, and babies whose mother have lactation failure till their milk output improves.
Challenges
Consent of mothers at both end (donating and receiving)
Screening and serological testing of mothers
Pasteurization of milk
Storage
Post Pasteurization culture of the pooled milk
Testing random milk samples for bacteriology before disbursal
Regardless of factors such as cultural acceptance, consent and others mentioned above, Nepal surely could benefit from having a milk bank. Human milk banking can become the next best thing in Nepal due to its convenience, ease, and economical affordances. Harnessing this untapped potential for saving infant lives can certainly improve our maternal and child health indicators in coming future.
Writers
Astha Karkee
Divya Mittal
Supriya Bhattarai