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With increasing recognition of the short-and long-term clinical benefits of human milk, and economic, social and clinical barriers to breastfeeding success, demand for donated milk is rising steadily. The recommends using pasteurized human donor milk as a first food for newborns when a parent鈥檚 own milk is unavailable for social or clinical reasons. This is particularly important for the preterm population who are at risk of serious complications from gut infections.

Human milk has always been shared among families; wet-nursing is a global and ancient practice. Human milk banks emerged about 100 years ago. At present, both non-profit and for-profit banks exist in North America; for-profit banks can and do compensate 鈥渄onors鈥� financially whereas non-profit banks only reimburse donor expenses, such as the cost of shipping or of materials including storage bags and cooler gel packs. With the rise of social media, peer-to-peer milk sharing is increasingly commonplace. Peer milk sharing Facebook sites such as Eats on Feets and Human Milk 4 Human Babies facilitate connections between donors and recipients and discourage payment. Milk shared between peers is generally unpasteurized. Human milk may also be purchased online, through private classifieds (usually unpasteurized) or through companies (pasteurized).

Four non-profit milk banks operate in Canada: the Public Mother鈥檚 Milk Bank operated by H茅ma-Qu茅bec in Montreal; the Rogers Hixon Ontario Human Donor Milk Bank in Toronto; the Northern Star Mother鈥檚 Milk Bank in Calgary; and the BC Women鈥檚 Provincial Milk Bank in Vancouver. The Human Milk Banking Association of North America (HMBANA) governs how non-profit milk banks operate. In distributing milk, member banks must prioritize the most fragile infants in neonatal intensive care units (NICU) as recipients. Although there is no milk bank east of Quebec, hospitals in New Brunswick, Nova Scotia and Newfoundland purchase milk from the banks in Calgary and Toronto.

HMBANA-member banks must conduct rigorous screening of donors for potentially risky behaviours, similar to blood donation screening. Donors are required to provide negative blood test results for HIV, hepatitis and syphilis. Donation must be approved by the donor鈥檚 health care practitioner. After pasteurization, donations are tested for any remaining contamination.听 HMBANA banks teach safe milk handling and re-educate donors if bacterial cultures are present after pasteurization.

Milk distributed by banks is subject to the . Section 4 prohibits sale of food that is harmful, unfit for human consumption, adulterated, or prepared in unsanitary conditions.听 Banks are subject to inspection to monitor compliance.

The first organized milk bank opened in , Austria, in 1909. The first milk bank in North America opened in 1919 in . Milk banking grew steadily throughout the 20^th century: in the 1980鈥檚 there were milk banks in Canada. During the HIV/AIDS crisis in the 1980鈥檚 , fears of transmission through breastmilk resulted in all of these banks closing, except for the BC Women鈥檚 Provincial milk bank, which has been open continuously since 1974. Nowadays donors have serology testing for HIV as well as other blood-borne infections.

Four milk banks now operate in Canada. Organized web-based milk sharing in North America began in about 2010 with the emergence of Facebook for platforms.

Because the HMBANA banks have operating expenditures, staff, and overhead, they charge approximately $4.50/ounce for pasteurized human donor milk. Milk that is provided in-hospital is prescribed and is covered by Medicare like all medications provided to patients while in hospital. Outside of hospital, no private insurer currently covers the cost of donor milk. This is because pasteurized human donor milk does not have a Drug Identification Number (issued by the Therapeutic Products Directorate of Health Canada) and required to be considered for third-party insurance coverage. Eligibility for a prescription for pasteurized human donor milk is determined by clinical and administrative considerations.听 For example, a hospital may have a policy that all infants born under 1800 grams or under 34 weeks gestation will be prescribed donor milk with parent/guardian consent to treat.

There are concerns that the cost of pasteurized milk limits its . Some suggest donors as an approach to increase donation.

HMBANA prohibits non-profit member banks from remunerating donors (for example, by the ounce), but allows reimbursement of actual expenses such as shipping costs. There is concern that payment for milk may result in the of marginalized populations; impact quality by creating an incentive to milk down; compromise safety in milk handling resulting in microbial ; affect donor disclosure about health status; and impact the donors鈥� other children because milk is sold that otherwise would be available to them.

For-profit human milk companies market products such as shelf-stable human milk and human-milk-based fortifier for the preterm population. There is a dearth of independent research about the effectiveness and cost-effectiveness of these products.

There is even evidence that individuals who attempt to sell milk online are subject to harassment, including requests for adult wet nursing and explicit photos.

There are more than 500 milk banks operating in over 37 countries around the听. This is a growing industry: in 2017 alone, HMBANA banks dispensed听听ounces of milk.

Concern about the exploitative nature of a Utah-based human milk company called Ambrosia Labs, which paid women in听听to pump twice daily and shipped the milk supply to US states, resulted in Cambodia banning the practice.

Several US states have legislation governing for-profit milk bank practices. For example, 听 include: requiring for-profit companies to follow HMBANA ; requiring donors to delay donating for a minimum amount of time postpartum; and stipulating that most of the bank鈥檚 supply be provided to fragile in NICU (neonatal intensive care units). In Canada, Health Canada and the Pediatric Society have guidelines regarding use of banked and shared human milk.

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