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 Table of Contents  
Year : 2018  |  Volume : 7  |  Issue : 4  |  Page : 191-197

Non-maternal nursing in the muslim community: A health perspective review

Family Medicine Department, College of Medicine, Al Imam Mohammad Ibn Saud Islamic University (IMSIU), Riyadh, Saudi Arabia

Date of Web Publication15-Oct-2018

Correspondence Address:
Dr. Fouzia Abdulaziz AlHreashy
MD, IBCLC, Consultant Family Medicine, Riyadh
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcn.JCN_55_18

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Non-maternal nursing is a valuable option for healthy infant nutrition. It is currently practiced as direct wet nursing and feeding of expressed milk from a wet nurse, and the applicability of both varies across cultures. Review of the relevant literature revealed an understanding of the characteristics, benefits, and challenges in the practice of wet nursing across different cultures. There is a paucity of literature on direct wet nursing in medicine. On the other hand, there is a considerable amount of discussion on the indirect method (donor human milk feeding) in the context of milk banks and feeding premature infants or sharing in the community. The ideal characteristics of a wet nurse and/or a human milk donor are addressed. The challenges that face non-maternal nursing include health, economic, cultural, and other challenges – the majority of which can be overcome at the individual or community level. Finally, in the context of Muslim communities, milk kinship should not be considered an obstacle to non-maternal nursing; indeed, it should be addressed as a fortunate feature that can expand human relations between the wet nurses and the receiving families. The findings of this review indicate the need for evidence-based guidelines for non-maternal nursing across various social context and clinical scenarios. Moreover, it is important to utilize modern technology in donor human milk feeding in specific situations to ensure that the benefits of human milk are extended to infants of all cultures.

Keywords: Direct wet nursing, expressed donor milk, milk kinship, Muslim community, non-maternal nursing

How to cite this article:
AlHreashy FA. Non-maternal nursing in the muslim community: A health perspective review. J Clin Neonatol 2018;7:191-7

How to cite this URL:
AlHreashy FA. Non-maternal nursing in the muslim community: A health perspective review. J Clin Neonatol [serial online] 2018 [cited 2019 Jun 17];7:191-7. Available from: http://www.jcnonweb.com/text.asp?2018/7/4/191/243339

  Introduction Top

Breastfeeding is the normative standard for infant nutrition and considered to be a public health concern.[1] The World Health Organization (WHO) acknowledges breastfeeding to be an investment in early childhood. Every US$1 invested in supporting breastfeeding generates an estimated US$35 in economic returns across low- and middle-income countries. Reducing health-care costs and ultimately advancing productivity will have a benefit to the national economy.[2] A cost–benefit analysis conducted in seven countries in Southeast Asia showed that inadequate breastfeeding contributed to over 12,400 preventable child and maternal deaths per year. The potential savings in health-care costs ($0.3 billion annually) from reducing the incidence of diarrhea and pneumonia could help offset the cost of promoting breastfeeding.[3]

The vast majority of mothers are capable of breastfeeding, just as the vast majority of infants are capable of suckling; the mother's milk is considered unsuitable for her infant only in exceptional situations. The best alternatives in circumstances where infants who cannot, or should not, be breastfed, are expressed milk from the infant's own mother, milk from a healthy wet nurse or a human milk bank, or a human milk substitute fed with a cup, which is a safer method than a feeding bottle and teat; the choice of method depends on individual circumstances.[4]

Before the invention of bottles and formula, wet nursing was the most common alternative to natural mother's milk, and this remains a privilege of wealthy families. Wet nursing was once a legitimate profession with numerous supporters as well as opponents. Milk substitutes were available by the end of the 18th century, and the dilemma shifted from breastfeeding versus wet nursing to human milk versus milk substitutes. As a result, the incidence of wet nursing reached its lowest point in the 19th century. In addition to providing biological benefits, wet nursing has functioned as a social, economic, and political force throughout history. In some cultures, wet nursing is not merely used as an alternative form of nutrition; it is also important for the establishment of milk kinship and as a marker of economic mobility or established alliances. Although wet nursing has declined with the introduction of bottle feeding, it remains a religious practice in many parts of the world.[5]

Details of wet nursing practices worldwide are currently unavailable; however, milk expression appears to be an increasingly prevalent practice, especially in countries with milk banks, where it is associated with maternal employment.[6],[7],[8] Indeed, the practice of wet nursing has made a comeback in the form of milk donation and milk sharing.[9] This review seeks to answer a series of questions:

  1. What is the current practice of wet nursing in the Muslim world?
  2. Is direct wet nursing preferable to the use of human milk expressed by a wet nurse?
  3. What are the ideal characteristics of a wet nurse?
  4. What are the health indications for non-maternal nursing?
  5. What are the challenges to wet nursing practice in the Muslim community?

I briefly review the reported trends in non-maternal human milk feeding and highlight their applications in medical practice. This review sheds light on the practice of wet nursing in the context of Islam. It also highlights the importance of identifying the source of human milk and presents the issues related to the establishment of human milk banks in Muslim communities. Furthermore, it addresses the need for evidence-based guidelines for non-maternal nursing that are in keeping with the culture and morals of the context in which they are applied.

  Basic Biomedical Sciences Top


Unlike infant formula feeding, breastfeeding has a characteristic variability in several physiological aspects. Human milk is a dynamic, bioactive fluid that changes from colostrum to mature milk in late lactation and varies within feeds, diurnally, and among different mothers.[7] The variability in macronutrient contents between mothers suggests that human milk analysis may improve the nutritional management of low-birth-weight infants.[9] Hence, selecting and identifying a wet nurse for the infant is highly important from both clinical and social perspectives.

Milk supply

The concept of expressing breast milk to increase supply has been addressed in lactation physiology.[1] This concept is applicable to wet nurses who feed two or more infants directly or through expressed milk. Indeed, lactation can be induced even in the absence of pregnancy, and regular stimulation is important for milk production.[10] Yet, the importance of monitoring an infant fed by a wet nurse or adopted mother cannot be neglected.

Dose response

The correlation between dose and the benefits of lactation is well documented.[11],[12],[13] The dose of human milk is usually described according to exclusivity, regularity, and/or the duration. The regularity of breastfeeding is commonly described by the terms exclusive, predominant, partial, token, any breastfeeding, and never breastfed.[14] Pang et al. observed that the duration of direct breastfeeding is longer than that of expressed human milk feeding.[15] Perceived insufficiency in milk production is among the most frequently cited reasons for formula supplementation and early breastfeeding cessation throughout the postpartum course;[16] consequently, increasing the dose of human milk from a non-maternal source may be a better option.

Skin-to-skin contact

Direct nursing is the basis of the beautiful dyad of lactation and motherhood. Skin-to-skin contact (also known as “kangaroo care”) is important for infant development. Infants who have regular skin-to-skin contact with their mothers have better coordinated sucking and swallowing patterns, stay warmer, and cry less, while mothers experience increased oxytocin release, a further boost in milk production, enjoyable bonding, and more confidence in their motherhood abilities.[17] Hence, direct wet nursing seems to be better than feeding solely with expressed milk, even if the milk is from the biological mother.

Milk expression

Lactating women can express their milk for storage by manual or mechanical means. However, storage changes the composition of the milk. For example, freezing decreases the effectiveness of some of the antibodies, damages some cells present in the milk,[18],[19] and degrades many milk proteins. The Academy of Breastfeeding Medicine has released protocols for human milk handling and storage.[20] Education of new mothers on expression and storage is recommended, irrespective of whether it is used for their own infant or for donation.[21]

Pasteurization of human milk

Pasteurization is an important technique for preventing the passage of bacterial and viral infections through milk. Walker[19] described the changes in milk composition with heating during pasteurization and with freezing. Heat-induced degradation of many proteins may alter the bioactivity of milk.[7] The choice of pasteurized milk from milk banks as opposed to unpasteurized milk sharing is a hot topic of discussion, with most favoring safe feeding of infants by wet nurses. However, direct wet nursing might provide better quality milk than pasteurized for infants who are able to suckle.

Genetics of human milk

Most of the benefits of breastfeeding are due to the cellular components of human milk [Figure 1]. Kaingade et al. recently highlighted the need for human milk cell banking, as living milk cells such as leukocytes and lymphocytes are significantly diminished or damaged by pasteurization and freezing.[18] Indeed, the genetic applications of the viable cells in human milk are an interesting area of future research and may account for the superiority of direct wet nursing over pasteurized human milk feeding. Moreover, identification of wet nurse(s) per child(ren) is valuable when milk kinship is a concern.
Figure 1: Components of breast milk. Source: Kaingade et al.[18]

Click here to view

  Methods of Non-maternal Nursing Top


The WHO/United Nations International Children's Emergency Fund defines breastfeeding as a method by which a child receives human milk directly from the breast or expressed.[14] A wet nurse has been defined as “a woman who breastfeeds another woman's child,”[22] “a woman who breastfeeds an infant other than her own for pay,”[23] or “a woman employed to suckle another woman's child.”[24]

Human “milk sharing,” which is rapidly spreading in the U.S.,[25] is “the noncommercial practice in which a donor gives expressed human milk directly to a recipient family for the purpose of infant feeding or breastfeeds a recipient infant.” Furthermore, recent studies have shown that milk-sharing donors and recipients use both online and offline social networks to facilitate these practices.[26] Informal sharing of unpasteurized human milk from donors should be practiced with caution.[27]

In 2012, there was a call for consistency in the definitions relating to the breastfeeding dyad (the relationship between the infant and the milk provider) and the method of feeding.[28],[29] Subsequent initiatives have begun to categorize maternal and donor human milk under the common term “human milk,” despite the marked differences in the composition, efficacy, associated costs, and health outcomes.[30] Systematic reviews on the health outcomes related to different types of breastfeeding and human milk use are required, and consistency between breastfeeding-related definitions and methods is necessary before interventions can be adequately developed and tested.[31]

The types of non-maternal nursing in infant nutrition are illustrated in [Box 1].

Direct wet nursing

Despite the absence of practical guidelines, direct wet nursing is widely considered to be a healthy practice. Compared with feeding expressed milk, several studies of the health and disease outcomes have indicated the benefits of direct lactation in terms of the following situations:

  • Direct breastfeeding may be advantageous compared to feeding of expressed milk in terms of reducing the risk of otitis media[32]
  • The suckling process in direct breastfeeding plays a role in the control of satiety and the prevention of rapid weight gain[33],[34]
  • Unlike direct breastfeeding, milk expression and storage require the use of technology[35]
  • The infant population is vulnerable to morbidity and mortality in disaster situations.[1] Thus, promulgation of direct breastfeeding and wet nursing practices may help save the lives of such babies.[1],[36],[37]

Indirect wet nursing

The other method of wet nursing is through the feeding of expressed human milk from a donor (wet nurse). This practice is of particular importance for high-risk infants, especially those with a very low birth weight.[27] The reasons for this are that premature infants find suckling at the breast difficult, and some mothers are unable to provide sufficient quantities of their own milk.

Experts recommend that high-risk infants are fed donor human milk obtained from milk banks.[27],[38] The American Academy of Pediatrics discourages the practice of informal milk sharing because of the increased risk of bacterial and viral infections, the transfer of drugs or medications, and the presence of cow milk protein. In fact, the practice of feeding expressed milk is also now observed with normal newborns in a nursery,[39] and informal milk sharing is observed in some communities.[40],[41] However, the concept of feeding donor milk to sick infants is not acceptable in certain communities.[42]

  Call for Medical Guidelines Top

Paucity of medical literature in wet nursing

Wet nursing is well described in the literature across different disciplines and especially in the social and religious sciences.[43],[44] Although wet nursing is an option listed in the WHO “Global Strategy for Infant and Young Child Feeding,” textbooks for physicians and allied health professionals barely mention the terms “wet nurse” and “wet nursing,” which seem to be recommended only in disaster situations or for emergency infant nutrition.[1] On the other hand, milk donation (indirect wet nursing) is well addressed, especially by the establishment of milk banks. Wet nursing is expected to benefit children, women, and society from physical, social, and psychological viewpoints. The conditions that necessitate non-maternal nursing can be medical or nonmedical; examples of such conditions are illustrated in [Box 2].

Ideal characteristics of a wet nurse

The ideal characteristics of wet nurse and/or human milk donor[45] are summarized in [Box 3] and indicate a holistic approach to health. Human milk donors for milk banks should be healthy lactating mothers,[46] and screening tools should be implemented to identify ideal donors. To be eligible as milk donors, women must not be on recreational or other drugs, and the approval of both their physician and the infant's physician is required. In addition, the milk bank is required to obtain a health history and blood samples for testing. The donors are usually screened for hepatitis B, hepatitis C, HIV-1, HIV-2, human T-cell leukemia viruses 1 and 2, and syphilis.[47]

  Focus on the Muslim Community Top

A considerable number of infants receive suboptimal nutrition in some Muslim communities,[48],[49] many of which have a low economic status, while others face various forms of political instability; thus, there is a strong need for promoting breastfeeding to improve maternal and infant health. In addition, many Muslims live in non-Muslim communities, and utilization of milk banks in emergency situations is a particular issue.[50]

Wet nursing is an option

Breastfeeding has a religious basis in Islam, which supports the employment of a wet nurse with mutual agreement from the parents when the mother is unable to breastfeed. This demonstrates the preference in Islam for human milk for infant feeding.[51] It is the father's responsibility to ensure that his child breastfeeds even if the birth mother is not able to breastfeed:[45] “And if you desire a wet nurse for your children, then no guilt shall be on you if you hand over what you have given with kindness” (Al-Qur'an al-Kareem: Surah Al-Baqarah: Verse 233). Moreover, it is appropriate to offer an incentive agreed by both the father and the wet nurse: “And if they suckle your (offspring), give them their recompense. And if ye find yourselves in difficulties, let another woman suckle (the child) on the (father's) behalf” (Al-Qur'an al-Kareem: Surah At-Talaq [Divorce]: Verse 65).

Hukum Tahrim

According to several tenets in Islam known as Hukum Tahrim, wet nursing creates impediments to marriage between a nurse and her nursling, as well as between male and female (strange) nurslings suckling from the same nurse:[45] “Forbidden to you are your mothers and your daughters and your sisters and your paternal aunts and your maternal aunts and brothers' daughters and sisters' daughters and your mothers that have suckled you and your foster-sisters” (Al-Qur'an al-Kareem: Surah An-Nisa: Verse 23). Hence, identification of the wet nurse/donor mother is essential and feeding anonymized donor human milk is not acceptable.

Indeed, in Islam, the frequency of breastfeeding is a marker of milk kinship (adoptive motherhood): “An infant that is breastfed by a woman other than his or her biological mother five times or more within the first 2 years of its life then becomes her son or daughter from lactation.”[43]

In Saudi Arabia, the Charitable Organization for the Care of Orphans launched the “Creating Relatives for Orphans through Breastfeeding” program, through which a volunteer mother is assigned an orphan child to breastfeed. As a result, the child will experience the desired health effects of breastfeeding and will be provided with familial roots that help improve his or her psychological and social well-being.[52] This project is an example of the holistic benefits of wet nursing for specific groups in the society.

Although the flexibility of the Sharia with regard to non-maternal nursing is well established, the use of milk banks is not permitted for Muslims owing to fear of the Tahrim mentioned earlier.[53] The concept of milk kinship in Islam is usually raised when preterm infants of Muslim families would receive donated human milk.[54]

The use of human milk banks among Muslims is controversial: the fatwa prohibiting milk banks in the Muslim world contradicts the bioethics of using the best nutrition to save the lives of preterm infants.[53],[55] In 2015, studies of the perception of human milk donation and milk banks among Turkish mothers in a Muslim community showed that the majority were against the establishment of Western-style human milk banks; however, their response to human milk banks when their religious concerns were relieved was more positive. Concerns regarding the risk of infections were also raised.[56],[57] A study in Malaysia showed that most Muslim mothers surveyed had a fair knowledge and favorable perception of human milk sharing. However, a detailed understanding of the related Islamic issues was significantly lacking, especially concerning the implications of the Islamic term “mahram.”[58]

Alnakshabandi and Fiester have indicated their desire to organize such banks in compliance with Islam.[59] The increasing migration of Muslims to other countries brings this issue to prominence, especially when dealing with sick premature infants in neonatal Intensive Care Units. The value of a multidisciplinary, culturally sensitive process for dealing with situations where there is a conflict between religious or cultural beliefs and clinical practice is essential to formulate a solution that considers cultural differences and allows the parents and clinicians to decide.[50],[59]


The availability of milk formulas and the established practice of feeding such formulas are major challenges to increasing the practice of breastfeeding, including wet nursing. Although non-maternal nursing is a valuable option in infant nutrition, many arguments have been made against wet nursing. The challenges that face the spread of direct wet nursing are summarized in [Box 4]. In a study of direct wet nursing in the Muslim community, Mobeirek identified various religious, economic, health-related, and psychosocial challenges[60] and showed that milk kinship was a prominent concern. Indeed, these challenges can be overcome by education, clinical assessment of wet nurses and parental support. The culture and morals of a community should be considered when promoting the practice of wet nursing.

  Conclusions Top

The options for non-maternal nursing vary in quality, feasibility, customs, and cost across communities; this is in addition to the physiological variabilities of lactation. Direct wet nursing is a valuable resource that should be encouraged with appropriate support from the medical community. Islam supports breastfeeding from mothers as well as from wet nurses. However, the parents must know the identity of the human milk donors as a mark of respect for the kinship created between the wet nurse and the infant according to Islamic law. Thus, there is a need for multidisciplinary, evidence-based guidelines for non-maternal nursing of healthy and sick infants that are in keeping with cultural norms.


I would like to extend special thanks to experts who support this publication and particular appreciation for Professor Abdulrahman Al. Frayh for his valuable comments.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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