When is donor human milk from a milk bank indicated for a preterm (<34 weeks gestation, <1500 g) or medically fragile newborn (e.g., necrotizing enterocolitis, congenital heart disease, severe gastrointestinal dysfunction), and how should it be obtained?

Donor Human Milk Indications for Preterm and Medically Fragile Newborns

Pasteurized donor human milk is indicated for very low birth weight infants (<1500g) when mother's own milk is unavailable or insufficient, and should be prioritized as the first alternative feeding choice before formula for preterm infants <34 weeks gestation. 1

Primary Indications

Very Low Birth Weight Infants (<1500g)

• Donor milk is specifically recommended by the American Academy of Pediatrics for VLBW infants when mother's own milk is not available or as a supplement to maternal milk. 1
• Mother's expressed milk provides documented short and long-term health benefits including reduction of necrotizing enterocolitis, late-onset sepsis, and improved neurodevelopment in this population. 2
• When maternal milk is insufficient, pasteurized donor milk remains superior to formula for reducing severe complications in premature infants. 3

Preterm Infants <34 Weeks Gestation

• These infants have incomplete coordination of sucking, swallowing, and breathing (which matures around 32-34 weeks), making human milk feeding particularly important. 4
• Late preterm infants (34-36 weeks) have decreased effective milk emptying and may consume only 45% of expected volumes per feeding, requiring closer monitoring and potential supplementation. 2

Medically Fragile Populations

• For infants with necrotizing enterocolitis, congenital heart disease, and severe gastrointestinal dysfunction, donor milk use has been extended at some institutions, though evidence for superiority over formula in these specific populations is less clear than for VLBW infants. 5
• The strongest evidence base remains for high-risk preterm infants, particularly VLBW infants. 5

How to Obtain Donor Human Milk

Through Human Milk Banks

• Donor milk should be obtained from accredited human milk banking facilities that screen donor mothers, collect, process, pasteurize, store, and allocate milk to recipients. 6
• Over 700 human milk banks exist globally, though significant gaps remain in South Asia and Africa. 6
• Pasteurized donor milk undergoes rigorous screening and processing to ensure safety, though some nutritional elements are inactivated by pasteurization. 3

Distribution Priority

• There is limited supply of donor milk in many regions, and distribution is typically prioritized for sick, hospitalized neonates. 7
• Very low birth weight infants receive highest priority for donor milk allocation. 5

Critical Pitfalls to Avoid

Informal Milk Sharing

• Informal milk sharing (donating and receiving expressed milk without going through a milk bank) carries significant risks for bacterial and viral transmission and lacks donor screening—this practice should be strongly discouraged. 7
• Health care providers must counsel families on safer alternatives through accredited milk banks. 7

Impact on Breastfeeding Rates

• A common concern that donor milk availability might decrease breastfeeding rates is unfounded. 3, 8
• Data from 4,277 VLBW infants across 83 Italian NICUs demonstrated that exclusive breastfeeding rates at discharge were significantly higher in centers with human milk banks (29.6% vs. 16.0%). 8
• The presence of a milk bank and use of donor milk in the NICU is associated with increased, not decreased, breastfeeding rates at discharge. 8

Supplementation Hierarchy

• When supplementation is medically necessary, the hierarchy is: (1) mother's own expressed milk, (2) pasteurized donor human milk, (3) standard infant formula. 2, 7
• Expressed maternal milk should always be the first choice before donor milk. 2

Feeding Implementation

Volume and Frequency

• Preterm infants require feeding 8-12 times per 24 hours (approximately every 2-3 hours). 2
• Day 1 intake should be approximately <100 mL total, rapidly increasing to 500-600 mL per day by days 4-5. 2
• Human milk (including donor milk) contains prebiotic human milk oligosaccharides that support beneficial gut microbiome development, particularly important for NEC prevention. 1

Quality Considerations

• Donor milk does not confer identical benefits to mother's own milk but remains distinctly superior to infant formula as a human milk substrate. 5
• The effect of milk type (mother's own vs. donor) on microbiome composition is dose-dependent in VLBW infants. 1