Human milk banks in the response to COVID-19: a statement of the regional human milk bank network for Southeast Asia and beyond

Despite the clear recommendations and supporting evidence, governmental and professional medical association guidelines on obstetric and newborn care for COVID-19 in countries in Southeast Asia were inconsistent with WHO guidance. A review of guidelines on pregnancy, intrapartum and postpartum care in the context of COVID-19 from 33 countries, including seven in Southeast Asia, collected from 21 March and 30 April 2020, found that Indonesia, Malaysia, the Philippines, and Singapore did not recommend skin-to-skin contact, early initiation of breastfeeding and rooming-in for mothers with confirmed COVID-19 [12]. Thailand also did not recommend skin-to-skin contact and early initiation but allowed rooming-in with two meters distance between the mother and the infant based on family’s preference [12]. There was no mention of skin-to-skin contact and early initiation of breastfeeding in the Myanmar and Vietnam guidelines, but Myanmar recommended unrestricted rooming-in while Vietnam recommended immediate separation [12]. Specific to infant feeding, Indonesia recommended direct breastfeeding with infection protection and control measures, Myanmar and the Philippines allowed breastfeeding based on family preference, while Malaysia, Singapore, Thailand, and Vietnam did not recommend it [12]. If direct breastfeeding is not possible, Myanmar, Philippines and Vietnam recommended the provision of expressed breastmilk [12]. It is also noteworthy that only the Vietnam guidelines explicitly recommended the provision of donor human milk when indicated [12].

Some of the countries later updated their guidelines or issued related guidelines to align with the WHO recommendations. The Thailand guidelines for care of newborns who were born from mothers with suspected or confirmed COVID-19 issued in April 2020 and the Philippines guidelines for the management of women about to give birth and newborns issued in July 2020 allowed skin-to-skin contact, early initiation of breastfeeding and direct breastfeeding under strict droplets precaution based on the mother’s preference after proper counselling [13, 14]. The KK Women’s and Children’s Hospital in Singapore, one of the largest hospitals in the country, issued its own guidance for breastfeeding and breastmilk feeding of infants of mothers who are suspected or confirmed to have COVID-19 in May 2020, which allowed rooming-in, direct breastfeeding with infection protection and control measures and feeding of expressed breastmilk based on mother’s decision after proper counselling [see Additional file 1]. The revised guidelines from Indonesia issued in September 2020 allowed early initiation of breastfeeding, direct breastfeeding with infection control measures and the provision of expressed breastmilk upon family’s preference according to clinical conditions and after receiving education [15]. The Philippines, Thailand and the KK Women’s and Children’s Hospital in Singapore also recommended the provision of donor human milk as a feeding option for infants of mothers with confirmed COVID-19 [13, 14].

For vulnerable infants (e.g. preterm, low birthweight, severely ill) who are unable to breastfeed or access their own mother’s milk, WHO recommends the safe use of donor human milk [16], and reiterated this in the guidance for COVID-19 [9]. When included in a package of interventions to protect, promote, and support breastfeeding, having access to donor human milk can protect the already vulnerable infant from life-threatening complications [17] and help mothers to establish their own milk supply and improve breastfeeding outcomes [18‐20]. Human milk banks play a significant role in their function to screen and recruit breastmilk donors, and then to collect, process, screen, store and distribute safe donor human milk [21]. Studies show that the process of Holder pasteurization of donor human milk, which is routinely done in human milk banks, can inactivate the SARS-CoV-2 virus [22, 23].

A total of 35 human milk banks are currently operating in five countries in Southeast Asia (Table 1), with a formal milk bank association convened in only one country (the Philippines). While there is currently insufficient data to accurately assess scale [24], human milk bank services play a critical role in providing donor human milk for vulnerable infants, especially during this crisis. As such, in countries with an established human milk bank, COVID-19 country guidelines should explicitly recommend the use of pasteurized donor human milk as a feeding option when a mother’s own milk is not available. The role of human milk banks in clinical management of COVID-19 needs to be integrated and clearly defined in newborn care guidelines. This is a prerequisite for full alignment with the evidence-based recommendations of WHO.

Outside of the recommendation on the use of donor human milk in the hierarchy of feeding options, there are currently no WHO guidelines specific to the operation of human milk banks. Countries have thus far relied on existing recommendations from regional milk bank associations [25, 26], expert groups [27], and other countries to inform local standards development. There is also relatively limited guidance regarding donor screening, raw milk handling, collection, and transport of donor human milk in the context of the pandemic, as well as guidance on long-term operational considerations for human milk banks in a post-pandemic setting. While some countries have included disaster risk reduction and response considerations in the operation of their human milk banks prior to the pandemic (e.g. dedicated emergency response supply in the Philippines), human milk banks in the region are generally not designed, nor are currently sufficient in capacity, to respond to large-scale emergencies, especially one as complex as COVID-19. The current pandemic is an opportunity to accelerate the development of WHO guidelines, to advocate for interventions to increase coverage of human milk bank services, or to establish human milk banks in countries where no such services are in place. It is also an opportunity to establish and sustain global partnerships to advance human milk banking through knowledge sharing and joint advocacy. This opportunity has not gone unrecognized. The global human milk bank community recently convened and issued a call to action [24], articulating the need to address fundamental bottlenecks to ensuring safe, equitable, and resilient implementation of human milk bank services in the context of COVID-19 and beyond.