|Year : 2023 | Volume
| Issue : 1 | Page : 22-26
Knowledge, attitudes, and perceptions of health-care workers about human milk banking in Singapore
Natalie Yi Ting Koh1, Chua Mei Chien2, Seyed Ehsan Saffari3, Rajadurai Victor Samuel2
1 Department of Paediatrics, KK Women's and Children's Hospital, Singapore
2 Department of Neonatology, KK Women's and Children's Hospital; Department of Neonatology, Duke-NUS Medical School, National University of Singapore; Department of Neonatology, Lee Kong Chian School of Medicine; Department of Neonatology, Yong Loo Lin School of Medicine, Singapore
3 Center for Quantitative Medicine, Duke-NUS Medical School, National University of Singapore, Singapore
|Date of Submission||04-Nov-2022|
|Date of Decision||12-Dec-2022|
|Date of Acceptance||14-Dec-2022|
|Date of Web Publication||03-Jan-2023|
Rajadurai Victor Samuel
Department of Neonatology, KK Women's and Children's Hospital
Source of Support: None, Conflict of Interest: None
Background: The use of human milk provides substantial short- and long-term benefits. With the establishment of the first donor human milk bank in Singapore, high-risk preterm and critically ill infants whose mothers have an inadequate milk supply can have access to pasteurized donor human milk. Materials and Methods: A self-administered anonymous questionnaire was conducted among doctors and nurses working in the special care unit and neonatal intensive care unit of KK Women's and Children's Hospital. The questionnaire was divided into three main sections, namely, demographics, knowledge assessment, and opinion. The aims of the survey were to assess the knowledge, attitudes, and perceptions of health-care workers on breast milk donation and milk bank, and to identify any differing perceptions among different racial and ethnic groups. Results: A total of 38 doctors and 140 nurses from various racial and religious backgrounds participated in this survey. More than 50% of respondents know the benefits of breast milk over formula milk; however, knowledge of the milk donation process and the effect of pasteurization on donated breast milk can be improved on. In the opinion section, 78.7% of survey respondents were supportive of the human milk bank. Sixty-eight (38.2%) respondents felt that recipients should receive milk from donors of the same race and ethnicity, whereas 56 (31.5%) disagreed and 53 (30%) were neutral. Conclusion: Donor human milk banking is well received and supported by health-care workers. Knowledge of milk donation, screening, pasteurization, and storage can be improved on. Further evaluation is required to determine the underlying concerns that different ethnic groups may have.
Keywords: Donor human milk, health-care workers, human milk banking, preterm infants, sick infants
|How to cite this article:|
Koh NY, Chien CM, Saffari SE, Samuel RV. Knowledge, attitudes, and perceptions of health-care workers about human milk banking in Singapore. J Clin Neonatol 2023;12:22-6
|How to cite this URL:|
Koh NY, Chien CM, Saffari SE, Samuel RV. Knowledge, attitudes, and perceptions of health-care workers about human milk banking in Singapore. J Clin Neonatol [serial online] 2023 [cited 2023 Jan 30];12:22-6. Available from: https://www.jcnonweb.com/text.asp?2023/12/1/22/366899
| Introduction|| |
Breastfeeding has been shown to provide numerous benefits to both babies and mothers. The World Health Organization recommends exclusive breastfeeding up to 6 months of age. When mother's own milk is unavailable or in short supply despite significant lactation support, donor milk represents the second-best alternative. There is increasing evidence that the use of human milk for sick and preterm infants provides substantial benefits including reducing the rates of infection, necrotizing enterocolitis, and mortality while improving neurodevelopmental outcomes. In the long term, it also reduces the risk of the development of childhood obesity and diabetes.
In Singapore, the prevalence of breastfeeding is suboptimal. The National Breastfeeding Survey conducted in 2011 found that at 2 months of age, less than half of the infants were being breastfed and the breastfeeding prevalence rate fell to 21.1% by 6 months. With the initiation of the first donor human milk bank program in Singapore, high-risk premature, very low birth weight or sick neonates whose mothers have an inadequate milk supply can have access to pasteurized donor human milk. An established milk bank also provides a safer and more regulated alternative to informal milk-sharing platforms that were previously used.
Health-care professionals play a key role in ensuring the success of this new initiative. Studies have demonstrated that health-care professionals who are knowledgeable and have a positive attitude toward breastfeeding, encourage mothers to comply with breastfeeding and support breast milk donation. However, the current literature with regard to health-care workers' perceptions of human milk banks is limited.
Several well-organized milk banks have been established in America, Europe, and Australia. Yet, this service is less recognized in Asian countries. As Singapore is a multiracial and multicultural society, different racial and ethnic groups may have differing viewpoints on this issue. Some ethnic groups may have certain concerns or resistance about the milk bank program, which may be an obstacle to its successful initiation.
Aims of the study
The aims of the study were to assess the knowledge, attitudes, and perceptions of health-care workers on breast milk donation and donor human milk banking, and to identify any differing perceptions among different racial and ethnic groups.
| Materials and Methods|| |
The survey was conducted in 2017 using a self-administered anonymous questionnaire. Hardcopy questionnaires were distributed to doctors and nurses working in the special care unit and the neonatal intensive care unit of KK Women's and Children's Hospital. The completed questionnaires were then collected and analyzed.
The questionnaire was divided into three main sections; demographics, knowledge assessment, and opinion. Questions on demographics included gender, age group, profession, years of practice since graduation, nationality, race, and religion. Knowledge questions were answered with True, False, or Undecided. Correct answers were determined according to evidence-based knowledge concerning the human milk bank. The opinion section is rated on a five-point Likert scale and respondents can select a "Strongly Agree," "Agree," "Neutral," "Disagree," or "Strongly Disagree" response to each statement. Descriptive statistics and χ2 test were used to analyze the data. The level of significance was kept below 0.05.
| Results|| |
A total of 38 doctors and 140 nurses participated in this questionnaire, making up more than 80% of the employed staff in the special care unit and neonatal intensive care unit. Of the doctors, there was an equal distribution of junior, middle grade, and senior medical staff [Table 1]. Descriptive statistics show that the sample was mainly: female (91%, n = 162), nurses (78.7%, n = 140), in age range 20–40 years (62.4%, n = 111), and Singaporeans (42.1%, n = 75). The respondents were predominantly from other racial groups (35.4%) or Chinese (31.5%) with a high proportion of Christians (50.6%).
The questionnaire had seven true or false statements with regard to milk donation, donor screening, pasteurization, and storage in the knowledge section. Responses were divided into correct, incorrect, and undecided responses, as demonstrated in [Table 2]. Two out of 7 questions drew more than 50% correct responses. Two questions (statements 4 and 5) had <20% correct responses.
|Table 2: Percentages of correct, incorrect, and undecided responses to statements assessing the respondent's knowledge about the human milk bank|
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Further data analysis using univariate analysis was performed to determine if there was a significant statistical difference between the proportion of correct responses and the type of profession. As shown in [Table 3], the proportion of correct responses by profession varies from question to question. Of note, there is a significant difference between the number of correct responses among doctors compared to nurses for the two questions evaluating the knowledge on the benefits of donor breast milk and its recommended use. The rest of the questions did not show any statistical significance among the responses from doctors compared to nurses.
|Table 3: Univariate analysis on the number of correct responses answered by doctors and nurses for statements 1 and 2 in the knowledge assessment|
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Survey respondents were given a list of 26 statements. Their opinions about the human milk bank were rated on a five-point Likert scale. Results are tabulated in [Table 4].
|Table 4: Percentages of responses assessing the respondent's opinions regarding the human milk bank|
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| Discussion|| |
From the knowledge section, it is evident that survey respondents are aware of the benefits of breast milk over formula milk and that donor breast milk should be used as a first alternative if the mother does not have sufficient breast milk supply. Responses to these two questions were also statistically significant among doctors compared to nurses. However, the survey highlights a gap in knowledge regarding the processes of human milk donation to the milk bank. For example, questions regarding the donor profile – such as whether cytomegalovirus seropositive women or women who smoke can donate to the milk bank – drew <50% correct responses. There was also a lack of understanding of the effect of pasteurization on the nutritional and immunologic components of donated breast milk. Research has shown that pasteurization reduces the immunologic factors of breast milk, particularly immunoglobulin A, but has no effect on the nutritional components.
For the opinion section, survey respondents were generally very supportive of the human milk bank in Singapore, with 78.7% of respondents choosing an "agree" or "strongly agree" response to this statement. The majority agreed that the human milk bank is an essential and cost-effective service and would use for the baby under his or her care. Regarding breast milk donation, most felt that donating breast milk is a worthwhile cause and should be promoted to all mothers in the postnatal period. Many supported options to facilitate breast milk donation such as having milk collection depots in the community and arranging for transport of donated milk. Support from health-care workers is especially important as Singapore has launched its first-ever human milk bank. Encouragement and help from health-care professionals have been shown to be associated with a higher prevalence of breast milk donation in the community.
Survey respondents acknowledged the importance of having specific guidelines to ensure that donated breast milk is prioritized for unwell babies most in need. Most also strongly agreed that donors must be carefully screened for transmittable infections such as hepatitis B, C, HIV, and syphilis and that donated breast milk must be of certain quality meeting international standards. Almost all respondents concurred that staff training on the various processes involved in human milk banking and using donated breast milk is imperative. Full-time staff members to run the milk bank are also necessary.
Whether donors should be paid for donating breast milk drew mixed responses, with 27% agreeing, 37.6% disagreeing, and 35.4% being neutral. In the literature, whether human milk donors should be offered a monetary sum continues to be an ongoing debate. Some feel that financial remuneration will be a source of motivation for donors, ensuring the sustainability of the milk bank. Others are of the view that donating human milk should be an act of altruism and that people should not donate with the intention of monetary gains. For example, in the United States, nonprofit milk banks that are accredited by the Human Milk Banking Association of North America do not pay donors for breast milk to minimize problems such as adulteration of milk that comes with financial remuneration.
The majority of survey respondents acknowledged that race and ethnicity are crucial factors in donating and receiving donated breast milk. 38.2% (n = 68) of respondents were of the opinion that recipients should receive milk from donors of the same race and ethnicity. Yet, 31.5% (n = 56) disagreed with the above statement, and the opinions of 30% (n = 53) of respondents were neutral. As Singapore is a multiracial and multireligious nation, there may be concerns within different religious and ethnic groups regarding the use of breast milk from a donor of different religions or ethnicities. To illustrate, in the Islam religion, accepting donor human milk establishes a milk kinship between the donor mother and the recipient of the milk such that the biological children of the donor mother and the recipient of the milk are regarded as "milk siblings" and are prohibited from marrying each other. A study done in Turkey, where almost 98% of the population follows the Muslim belief system, showed significant resistance against the establishment of a Western-style human milk bank in view of religious concerns. In the local context, this brings potential challenges when the donor or recipient is of different religious or cultural views.
| Conclusion|| |
This study provides a better understanding of the challenges of initiating and establishing the human milk bank in Singapore. Most survey respondents understand the benefits of breast milk and are supportive of the human milk bank. Greater understanding of the human milk bank and its processes need to be promoted through various educational channels. It is only when health-care workers are adequately equipped with this knowledge can greater awareness be spread among the general population, thereby ensuring the continued success of this new initiative. Whether donors and recipients should be of the same racial and religious background drew mixed responses and further evaluation is required to determine the underlying concerns and reservations of different ethnic groups.
The authors would like to thank the doctors and nurses who participated in the survey.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Binns C, Lee M, Low WY. The long-term public health benefits of breastfeeding. Asia Pac J Public Health 2016;28:7-14.
Arena Ansotegui J. Breastfeeding in the "global strategy for infant and young child feeding." An Pediatr (Barc) 2003;58:208-10.
Zipitis CS, Ward J, Bajaj R. Use of donor breast milk in neonatal units in the UK. Arch Dis Child Fetal Neonatal Ed 2015;100:F279-81.
Chinea Jiménez B, Awad Parada Y, Villarino Marín A, Sáenz de Pipaón Marcos M. Short, medium and long-term benefits of human milk intake in very-low-birth-weight infants. Nutr Hosp 2017;34:1059-66.
McGuire W, Anthony MY. Formula milk versus preterm human milk for feeding preterm or low birth weight infants. Cochrane Database Syst Rev 2001;(3):CD002972.
Foo LL, Quek SJ, Ng SA, Lim MT, Deurenberg-Yap M. Breastfeeding prevalence and practices among Singaporean Chinese, Malay and Indian mothers. Health Promot Int 2005;20:229-37.
Radzyminski S, Callister LC. Health professionals' attitudes and beliefs about breastfeeding. J Perinat Educ 2015;24:102-9.
McGuire W, Anthony MY. Donor human milk versus formula for preventing necrotising enterocolitis in preterm infants: Systematic review. Arch Dis Child Fetal Neonatal Ed 2003;88:F11-4.
Ayiku L, Banks, E, Chamberlain K, Carson C, Elliott N. Donor Breast Milk Banks: The Operation of Donor Milk Bank Services Guidance. Clinical Guidance (CG93). National Institute for Health and Clinical Excellence (NICE). Available from: https://www.nice.org.uk/guidance/cg93/chapter/Recommendations
. [Last updated 2018 Jul; Last accessed on 2022 Dec 22].
Storage, Handling, and Administration of Expressed Human Breast Milk: A Review of Guidelines [Internet]. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health. Available from: https://www.ncbi.nlm.nih.gov/books/NBK368235
. [Last updated on 2016 Jun 01; Last accessed on 2022 Dec 22].
Kim J, Unger S. Human milk banking. Paediatr Child Health 2010;15:595-602.
Peila C, Moro GE, Bertino E, Cavallarin L, Giribaldi M, Giuliani F, et al
. The effect of holder pasteurization on nutrients and biologically-active components in donor human milk: A review. Nutrients 2016;8:477. [doi: 10.3390/nu8080477].
Meneses TM, Oliveira MI, Boccolini CS. Prevalence and factors associated with breast milk donation in banks that receive human milk in primary health care units. J Pediatr (Rio J) 2017;93:382-8.
Relton C, Strong M, Thomas KJ, Whelan B, Walters SJ, Burrows J, et al
. Effect of financial incentives on breastfeeding: A cluster randomized clinical trial. JAMA Pediatr 2018;172:e174523.
Gribble KD. "I'm happy to be able to help:" Why women donate milk to a peer via Internet-based milk sharing networks. Breastfeed Med 2014;9:251-6.
Updegrove KH. Donor human milk banking: Growth, challenges, and the role of HMBANA. Breastfeed Med 2013;8:435-7.
Karadag A, Ozdemir R, Ak M, Ozer A, Dogan DG, Elkiran O. Human milk banking and milk kinship: Perspectives of mothers in a Muslim country. J Trop Pediatr 2015;61:188-96.
[Table 1], [Table 2], [Table 3], [Table 4]