Mother’s milk is the best food, packed with nutrients, for your newborn. Human milk has a complex nutritional composition that is difficult to replicate. Exclusive breastfeeding practices, followed by early initiation, feeding colostrum, and voiding prelacteal feeds are important for proper nutrition, growth, and development of the infant. Though the WHO recommends practicing exclusive breastfeeding from the first hour of life to six months, the rate of exclusive breastfeeding remains low in both low-income and middle-income countries.
The breastfeeding rate within the first hour after birth is 44% worldwide. The target set by the WHO to improve the rate to 70% is still not achieved. Out of 129 countries, only 23 countries have achieved an exclusive breastfeeding target of at least 60% of infants (less than six months of age) (WHO, 2017). 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. So, most of the infants are given colostrums; however, very few receive breast milk within the first hour of birth.
The biological composition of human milk is very dynamic and varies within each feeding between mothers and among populations. The variation in the composition is influenced by environmental and maternal factors. There are different stages of milk. 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, and is formed at the end of the pregnancy and the first few days after the birth. It’s present usually in small amounts, and has a thick, yellow, and sticky texture. However, sometimes it can be thin, white, or orange in colour, too. Immunological factors IgA, lactoferrin, and leukocytes are present in colostrums, which exerts typical immune-protecting function in colostrum. Other developmental factors like epidermal growth factor are also present in 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 five 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 has higher carbohydrate and fat content. Mature milk comprises about 90% water, which fulfils the 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.
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 in 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 important immunological function. It acts as prebiotics promoting the intestinal growth of commensal bacteria, especially Bifidobacteriumlongum sub sp infantis and B. bifidum. HMOs also act as receptor analogues binding with the receptor and inhibiting the binding of pathogens, including rotavirus.
Proteins provide around 8% energy to the babies; however, its concentration varies accordingly. Colostrum contains 30-70 g/l of protein, which then falls to a stable level of 7-14 g/l in mature milk. The proteins present are whey and casein and proteins linked with the membrane of the milk fat globule. Over 415 proteins have been identified in human milk; many are active with 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 proteins work in symbiosis to inactivate, destroy, or bind to specific microbes, preventing their attachment to mucosal surfaces.
The majority of a 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.
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.
These components affect biological processes or substrates, and so can influence the body’s function and overall health. Human milk is not only solely nutritional, but also contains a variety 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: immune-modulation, 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 six months of life, and in addition to other complementary foods for at least the first two years. There are numerous health benefits of breastfeeding the baby:
• Antibodies present in the milk help to protect babies from various infections 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, it 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 the least expensive way to feed an infant, and it facilitates bonding between mother and child.
In studies performed, it has been found that the infant mortality risk decreased by 12% in breastfed babies, as compared to those not breastfed. Decrease in respiratory, as well as gastrointestinal infections, was 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, and ovarian and breast cancers.
Milk bank as a way forward
Low birth weight is one of the major challenges in the maternal and infant health sector in both developing an developed countries. Every year, the WHO estimates about 25 million low birth weight babies, and nearly 93% of them are in developing countries, with the highest incidence (27%) in south Asia. In Nepal, the percentage of new-borns with low birth weight (< 2.5 kg) is 11% at the national level, and ranges from 15.9 % to 6.9 % in different provinces (DoHS, Annual Report 2073/74 (2016/17).
Majority of times, low birth weight is a consequence of preterm birth, or small size of gestational age, or both, and these infants are at high risk of various diseases (diabetes, heart diseases, metabolic syndrome) in later life. Therefore, interventions to improve low birth weight not only improves the immediate health, but also long-term health and well-being of the individual infant, and will have significant impact in the maternal and child health indicators of the country’s population.
The recommendation by the 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, and finally, the other alternative is formula milk. However, compared to formula milk, donated human milk is associated with low incidence of necrotizing enterocolitis and other gut disorders, as well as infections. The international milk banking initiative was founded in 2005, following a joint statement of the WHO and UNICEF supporting donated human milk. It lists 33 countries 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 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, and babies of mothers with postpartum illnesses, as well as babies whose mothers have lactation failure, till their milk output improves.
• Consent of mothers at both ends (donating and receiving)
• Screening and serological testing of mothers
• Pasteurization of milk
• Post pasteurization culture of the pooled milk
• Testing random milk samples for bacteriology before disbursal
Regardless of factors like acceptability, consent, and others mentioned above, Nepal surely could benefit from having a milk bank, and who knows, human milk banking can be the next best thing (convenient, easy, and economical) for saving infant lives and improving our maternal and child health indicators in the coming future.