Donor Human Milk for Muslim Infants in the United Kingdom
T C Williamsa, M Z Buttb, S M Mohinuddinc,d, A L Ogilvy-Stuarte, M Clarkef, G A Weaverg , M S Shafib
a Simpson Centre for Reproductive Health, Royal Infirmary of Edinburgh, Edinburgh, UK
b Muslim Council of Britain, London, UK
c Neonatal Transfer Service, Barts Health NHS Trust, London, UK
d School of Health Sciences, City University, London, UK
eNeonatal Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
f Department of Anthropology, University of Oxford, UK
g United Kingdom Association for Milk Banking, The Milk Bank, Queen Charlotte's and Chelsea Hospital, London, UK
Address correspondence to: Thomas Williams, Neonatal Unit, Simpson Centre for Reproductive Health, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, United Kingdom [, +44 (0)131 242 2567 .
Donor human milk (DHM) is currently used in Neonatal Units (NNUs) for feeding preterm infants when own mother’s milk (OMM) is not available or insufficient. In 2014, the latest Cochrane review1 showed that in preterm and low birth weight infants, feeding with formula compared with DHM results in a higher risk of developing necrotizing enterocolitis (NEC). As the incidence of NEC increases in relation to the other complications of preterm birth, 2 there is growing interest in the use of DHM, as evidenced by an expansion in the number of milk banks worldwide (currently over 500 in 44 countries). 3 In the United Kingdom it is estimated that 75% of Neonatal Intensive Care Units 4 use DHM for the feeding of infants, most commonly for those at high risk of NEC.
However, one part of the world where the use of DHM is not growing is in countries with predominantly Muslim population. Here, the introduction of anonymised DHM has been challenged by the Islamic concept of milk kinship. The sharing of human milk, historically in the form of a wet nurse, creates kinship ties and thus marriage prohibitions between the family of the donor and recipient.5 Surveys have shown that these beliefs may also affect the acceptability of DHM to Muslim parents in the United Kingdom. 4,6 It appears that these beliefs impact on the use of DHM predominantly in Neonatal Units in areas of the United Kingdom with substantial Muslim populations (C. Zipitis, personal communication ; S. Mohinuddin, unpublished data). Given the clinical benefits of DHM, we met to see if we could find a resolution to this situation. We felt that concerns about milk kinship need not lead to inequitable access to the management options available to this vulnerable patient group.
Adopting an approach which has been successful in the past, 7 we convened a Round Table Discussion between representatives of the main stakeholders: the patient population (Muslim Council of Britain), clinicians (British Association of Perinatal Medicine), the religious community (Muslim chaplains), and providers of DHM (UK Association for Milk Banking). To facilitate a constructive dialogue, we invited an expert in Islamic Bioethics (MC) to place the use of DHM for Muslim infants in religious, social and historical context.
At an information sharing meeting in London, a resolution was found by referring to the National Institute for Health and Care Excellence (NICE) Guideline. 8 The guideline states that every aliquot of DHM given must be traceable from donor to recipient, in line with the donation of other human products such as blood, due to concerns about the potential transmission of infection. This requirement will be reinforced in the soon to be published BAPM Framework for the use of DHM in the United Kingdom, which will re-emphasise the need for a robust system to ensure the traceability of donated milk.
The primary concern from Muslim families about the use of DHM is that people who are, without knowing it, milk kin, may in the future unwittingly marry their milk sibling. We believe that the requirement for traceability should allow us to reassure these parents. In the situation wherea potential bride or groom had received DHM as an infant, traceability means that it would be possible to know whether they had received the milk from their prospective mother-in-law (the donor), thus making their intended spouse their milk sibling. Such a question would be answered by reviewing the medical records of the infant who had received milk, in conjunction with records from the relevant Human Milk Bank. With consent from the potential mother-in-law (as the current system guarantees anonymity for donors), the Milk Bank would be able to rule out, with a binary answer of yes/no (thus maintaining anonymity of other donors) whether the couple had received milk from the same lactating mother. In a situation where a future bride and groom had both received DHM in infancy, the Human Milk Bank could review their records to check whether they had received DHM from the same donor, which would not require this limited waiving of anonymity. In the future, electronic barcode tracking will be introduced to Human Milk Banks and their associated NNUs. This will make the process more straightforward, and is also likely to facilitate the extension of the current 30 year limit for the retention of medical records as mandated by NICE. In a situation where clinical and religious needs initially seemed to be in conflict, we found that they in fact appear to coincide.
We are aware of similar efforts taking place worldwide to minimise barriers to the uptake of DHM. In Turkey, an alternative milk banking model compatible with Islamic beliefs was set up in 2013, but awaits final legal approval from the Ministry of Health. Here, donors and the families of prospective recipients will meet prior to milk donation, and details of the donation will be recorded electronically.9 In Malaysia, milk donation from a donor mother to a maximum of two recipient infants will be facilitated by Neonatal Intensive Care Units, and records kept by both the hospital and various State Religious Departments (N. Haliza, personal communication). Our initiative should work in parallel with these projects, hopefully reinforcing their efforts, but also gaining credibility through the existence of similar such initiatives in majority Muslim contexts.
We believe we have shown the value of a multi-disciplinary, culturally sensitive process for dealing with situations where there is conflict between religious or cultural beliefs and clinical practice. In this instance, it allowed for the formulation of a solution which respects cultural differences, and provides choice to parents and clinicians, regardless of their religious beliefs. As evidenced by similar work ongoing in Malaysia and Turkey, we believe that our approach, or variations of it, could be adopted by other areas with significant Muslim populations, with potential benefit for infants at risk. Initiatives such as this one, which take seriously the importance of fostering dialogue between different constituencies within society or indeed between different cultures, are also, we believe, of wider social significance.
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The authors declare no competing interests.
Acknowledgements: We would like to thank Dr. Noor Haliza Yussoff from the National Lactation Centre of the Ministry of Health, Malaysia, and Prof . Sertac Arslanoglu from the İstanbul Medeniyet University School of Medicine, Turkey, for sharing information about the use of DHM in their countries.
1Quigley M, McGuire W. Formula versus donor breast milk for feeding preterm or low birth weight infants. Cochrane database Syst Rev 2014; 4: CD002971.
2Patel RM, Kandefer S, Walsh MC, et al. Causes and Timing of Death in Extremely Premature Infants from 2000 through 2011. N Engl J Med 2015; 372: 331–40.
3Strengthening Human Milk Banking: A Global Implementation Framework. (accessed Feb 3, 2015).
4Zipitis CS, Ward J, Bajaj R. Use of donor breast milk in neonatal units in the UK. Arch Dis Child Fetal Neonatal Ed 2014; published online Dec 24. DOI:10.1136/archdischild-2014-307606.
5Clarke M. The modernity of milk kinship. Soc Anthropol 2007; 15: 287–304.
6Williams TC, Menon G, Weaver G. Donor Human Milk for Infants of Muslim Parents. In: European Society for Paediatric Research Annual Meeting. 2013.
7Department of Health. Uniforms and workwear: guidance on uniform and workwear policies for NHS employers. (accessed Nov 13, 2015).
8NICE. CG93 Donor breast milk banks: NICE guideline. (accessed March 3, 2013).
9Arslanoglu S. Where East Meets West: The Turkish Milk Banking Model. In: Abstract Book of 2nd International Congress of the European Milk Bank Association (EMBA). 2013.