Eight-year operation status and data analysis of the first human milk bank in East China

Cost of the HMB

This study describes the operations of our HMB and analyzes the data gathered over the last 8 years of its existence. Over the 8-year period, the total expenditure of the HMB was 1.94 million RMB($306,051), including employee salary, materials costs, test costs, etc., and both the donation and provision of DHM were free. The average cost per liter of qualified DHM was ¥262($41.4). In comparison, studies from the United States have calculated that 1 L of DHM costs approximately US $150, and studies from Germany have reported a cost of $94 per liter of DHM [12,13,14]. The costs of our HMB are probably lower because most donors are not required to repeat the HBV,HCV,HIV and syphilis test when they donate within 6 months of their serological test, which is done during hospitalization at the time of delivery at our hospital. The cost of providing DHM is much higher than the cost of formula and mother’s own milk. However,breastfeeding could reduce the incidence of diseases, such as necrotizing enterocolitis and late onset sepsis, and save a lot of future medical costs [15]. Therefore, we also advocate and promote breastfeeding through various means, such as propaganda and education of breastfeeding to parents and medical staffs, etc., at our HMB.

Characteristics of human milk donors

Over the 8-year period, a total of 250 mothers(13.9%) did not meet the criteria for donation because they did not pass the health screening or serological test or their DHM did passed the bacteriological tests (Table 1). In 2015, a total of 169 mothers did not qualify because the CMV-DNA test of their DHM was positive, and this phenomenon exists in most Chinese mothers [16]. In fact, after pasteurization or freeze, the CMV-DNA test shows negative results, which means that the donor milk is not likely to cause neonatal infection [17]. Thus, after the continuous quality improvements that were initiated in January 2016, we only used the donors’ serum CMV test(including IgG and IgM) for screening.

During the last 8 years of operation of the HMB, the number of qualified donors and the volume of qualified DHM first showed an increase and then a decrease. In 2016, we carried out quality improvement programs for the HMB, including conducting propaganda and education of breast milk feeding, establishing education sites of breast milk donation, maternal and child health publicity in shopping mall, improving the process of breast milk donation and processing, ect. [11]. These programs resulted in a considerable increase of the number of qualified donors(304) and the volume of qualified DHM(1519.3L).In the first three months of 2020, due to the restrictions policy for donors coming to the hospital, our HMB did not receive any DHM no matter collected at home or at our HMB.Then the epidemic eased and our HMB gradually returned to normal work. Therefor, the number of qualified donors(46) and the volume of qualified DHM(537.9L) decreased significantly in 2020.

Our donors were mainly aged between 25 and 30 years, and this is similar to the donor demographic of HMBs reported in Taiwan and Thailand [18, 19]. 33.3% of the donors in the present study delivered preterm infants. It is mainly because the mothers of preterm infants have a reduction in postpartum lactation due to physical reasons [20] and they did not have added breastmilk for donation. In the present study, 61.2% of donors gave birth by vaginal delivery. This percentage is different from that reported in Thailand [17], but is similar to a previous report in mainland China [7]. Further, 46.2% of the donors in this study donated more than 10 times, which is higher than the percentage reported in mainland China and indicates that we have a higher average number of donations than other domestic HMBs. This is probably attributable to the efforts of our staff in providing correct information and following up with donors. Additionally, 62.6% of the donors had a bachelor’s degree, which meant well-educated mothers tend to have better knowledge about and attitude towards milk donation [21]. Most of the donors began to donate milk at 1 month postpartum at the earliest, and the number of donors who started to donate deceased rapidly at 3–6 months postpartum. The main reason is probably that most women in China are only given 4–6 months of maternity leave. Once they resume work, their free time and volume of lactation probably decrease dramatically.

Pasteurization

Although holder pasteurization (HoP,62.5°C for 30 min) may reduce the immunological components in donor milk, such as sCD14, however, this has little impact on the protein, fat, carbohydrates, some trace elements, and the activity of some enzymes [5, 22] that are very important and irreplaceable for the development of neonates, especially premature infants. Recently, a high-temperature short-time treatment(HTST, 72°C for 30s) was designed as an alternative for HMBs, which resulted in better preservation of the nutritional quality of DHM than HoP because relevant thermosensitive components (phospholipids, PUFAs, and BSSL) were less affected [23]. But we still choose HoP instead of HTST because the duration of HTST treatment, which had a greater influence on the nutrient composition of DHM than did the tested temperature, was harder to control [23].

Recipients

The DHM in our HMB was only supplied to the neonates in our NICU and was not continued after discharge, and it was provided free of cost. This model is different from that described in previous reports from Thailand and the UK,which provide DHM for non-hospitalized infants [24, 25]. During the 8-year period, 9,207 newborns received DHM, most of whom were premature infants (80.1%), and the newborns had severe infection, feeding intolerance, and necrotizing enterocolitis. The maximum volume per neonate was 13.7 L, which was used by an extremely premature infant. The duration of use of DHM was mostly less than 15 days, and the average duration was 4.5 days, which is shorter than that previously reported in Scotland [26]. This is probably because most mothers have expressed enough breast milk to feed their own babies after a certain time point.

Impact of COVID-19

During the COVID-19 pandemic, China implemented strict restriction policy, so we also added COVID-19 nucleic acid testing to the donor screening tests. Visitation was forbidden during newborn hospitalization, and patients from other provinces were not admitted to come to our hospital until recently. From February 4th to March 4th 2020, breast milk donation and transport to the hospital were not allowed in our hospital. These policies led to a significant reduction in both the number of donors and volume of DHM. Although this was accompanied by a significant reduction in the number of newborns as well as the demand for DHM in our hospital, due to pregnant women in other cities could not come to our hospital for childbirth, these conditions also led to the depletion of DHM stored at our HMB. However, it is worth noting that there was no case of COVID-19 infection at our hospital during this period.

Conclusion

HMBs could support and promote breastfeeding, and provide better choices and better nutritional treatment options for children who cannot be breastfed by their mothers, especially premature infants. Additionally, it is very important in raising social awareness about the benefits of breastfeeding or DHM feeding, and actively publicize and provide breastfeeding guidance. Over the 8 years of operation of our HMB, through continuous quality improvement, our processes have been gradually finetuned and made efficient, and we will continue to provide DHM to newborns in the future, and provide some recommendations to other HMBs operating in China.

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