How breast milk banks could avert the next formula crisis

Rio de JaneiroFive days after the early delivery of her baby last month at a municipal hospital, Talita Alves Araújo Lourenço sat in a chair while a nurse helped her express breast milk into a glass jar.

Araújo, 20, had given birth at 32 weeks; she had known early delivery was likely because she had been diagnosed with preeclampsia. At first, her baby could only drink her milk through a tube, but even after developing the strength and coordination to feed from her breast, Araújo was producing too much. The nurse was helping her to empty her breasts so they would feel more comfortable and to donate the extra milk.

“To know that my milk could be saving someone is very important to me,” says Araújo.

While the ongoing formula shortage that began in February 2022 affected families of infants who couldn't find supplies at the store, it also renewed interest in donation of breast milk to milk banks that supply it to hospitals for vulnerable newborns.

Brazil is widely considered the world’s leading example of milk banking because of a program started in the 1980s that combined promotion and training in breastfeeding with donation. The country today runs 228 of the world’s approximately 750 human milk banks. The United States, by comparison, has 28 that are members of the Human Milk Banking Association of North America.

Establishing a breastfeeding relationship

It would be a few more days before Araújo’s child gained enough weight to be released from the Hospital Municipal Lourenço Jorge - Maternidade Leila Diniz. In the meantime, Araújo went back and forth between her home 30 minutes away to spend time with her daughter and breastfeed. The hospital has a kangaroo care room, where mothers are taught the practice of bonding skin-to-skin by placing the baby upright against their bare chest and to establish breastfeeding. Mothers have a bed, meals and laundry facilities. A limited number of spots are available in the hospital for overnight stays.

It is increasingly common for hospitals around the world to promote breastfeeding soon after a baby is born, but it’s much harder for babies with health issues. Many of them have a delay in breastfeeding, and the mothers are not taught how to keep up their supply in the meantime, which is troublesome in countries where water quality makes cleaning bottles risky, and formula is too expensive for many.

In the kangaroo care room, many mothers who have more milk than is needed for their babies are also given the option to donate. Even once mothers have left the hospital, the breastmilk donation process is made easier because hospital lactation centers send workers to the home of donors to drop off sterilized glass jars and pick them up when they’re filled. The milk is then pasteurized, tested, and given a label based on such qualities as caloric value and acidity.

As needed, a single mother’s milk is paired up with a baby who hospital workers believe would be the best candidate for it. For instance, if there’s a baby who needs to gain weight, it might get a more calorie-heavy milk while another baby with low levels of calcium in the blood could benefit from a low acidity milk.

“The main difference of the model compared to other countries is the government support and that breastfeeding support goes along with milk banking,” says Danielle Aparecida da Silva, the technical director of the Brazilian National Network of Human Milk Banks.

How Brazil began its milk banking program

Back in the late 1970s, Brazil had a system much like the U.S., in which breastfeeding support at hospitals was separate from the work of milk collection. Back then, João Aprígio Guerra de Almeida was a young biomedical researcher looking at methods of collecting and preserving breast milk. He ultimately found that the processes used by the country’s three milk banks had serious quality control issues.

At the time, there was a major push to increase breastfeeding, and Almeida was soon put in charge of the country’s developing milk banking program. By 1986, he established a new model. First, it was important that milk be supplied by donation only, so that those lactating were not encouraged to neglect their own babies. To maintain a steady supply, it made sense to combine breastfeeding promotion with milk collection.

Also, Almeida found that the largest cost of running a bank, about 85 percent, was simply to buy medical grade glass products to store the milk. Instead, he switched to repurposed food containers, such as mayonnaise and coffee jars, which were just as safe and could be donated. Instead of foreign-made pasteurization machines, he also started using locally made laboratory food testing equipment, which were cheaper and could perform the same function to determine the nutritional value of the milk.

Over time, more and more milk banks opened with this new system and were advertised on the radio and television. The centers, located in hospitals, became places where people could store their milk after pumping it for later use, before it became more common for workplaces to have lactation rooms. There were also collection centers where people could drop off their breast milk.

In some cities, there weren’t enough government-owned cars to reach all donors’ homes, so the centers worked with firefighters, who were trained in how to safely store the milk. Postal workers were recruited for breastfeeding promotion. They knew who on their mail delivery routes would be giving birth and could use some information about lactation support.

Between 1990 and 2015, Brazil cut its mortality rate for children under five years old by 73 percent, according to the United Nations Children’s Fund, or UNICEF, in part because of this program, but also due to other efforts to increase immunization and financial aid for low-income families. While renowned, Brazil’s network of human milk banks is still only able to serve about 60 percent of preterm and low birth weight babies, according to Fiocruz, the country’s top biological sciences research foundation.

“If there was an ethical compass of milk banking, the arrow would point to Brazil,” says Summer Kelly, president-elect of the Human Milk Banking Association of North America. “The Brazilian milk bankers' unrelenting focus on the support and protection of the breastfeeding mother inspire and motivate other milk bankers around the world.”

Serving as a model for other countries

As Brazilian milk banks have gained international recognition, other countries have worked with Brazil to implement similar programs. Today, most countries in South America as well as Cuba, the Dominican Republic, Cape Verde, Mozambique, and Angola have established milk banks in the same model.

PATH, a global health organization, has also worked with countries including India, South Africa, Vietnam, and Kenya to implement breastfeeding programs based on Brazil’s. In Kenya, for instance, the first human milk bank in East Africa was established as a comprehensive model, linked with breastfeeding, adapting Brazil’s approach to the local context.

“When we work in a country, that’s the model that we really work with the governments to establish,” says Kiersten Israel-Ballard, Team Lead of PATH’s Maternal Newborn, Child Health and Nutrition program. “If you prioritize donor milk but you’re not helping the mother, that’s not sustainable. The priority is that they’re provided help to breastfeed as a long-term solution.”

For Ana Clara Benevenuto Mattos de Andrade, donating milk has become something of a family tradition. More than 20 years ago, her brother was hospitalized as a newborn, and their mother donated milk while receiving help learning how to feed him from a lactation center. When Andrade had excess milk following the birth of her own child, she decided to donate too. She has been sending weekly bottles to the milk bank at Núcleo Perinatal do Hospital Universitário Pedro Ernesto in Rio de Janeiro for four months.

“Unfortunately, when babies are hospitalized, there are mothers who can’t afford going to the hospital every single day to feed them; this is the reality of lots of families in Brazil,” says Andrade. “I feel the need to help those mothers and babies.”