Journal of Human Lactation

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Donor Milk Banking and Breastfeeding in Norway

Anne Hagen Grvslien and Morten Grnn
J Hum Lact 2009 25: 206
DOI: 10.1177/0890334409333425
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Currents in Human Milk Banking

Donor Milk Banking and Breastfeeding in Norway
Anne Hagen Grvslien and Morten Grnn, MD, PhD
Abstract
Milk banks in Norway have a long tradition of using raw milk. This is a practice the authors
hope to continue as they see it as the best choice until a childs own mothers milk production
is sufficient. Not only will the premature babies benefit from having milk from the bank, but
if a mother, for any reason, can not supply her baby while its in the hospital her baby should
be offered milk from a bank. In Norway, with a high breastfeeding rate this can be done at
many hospitals. J Hum Lact. 25(2):206-210
Keywords: breastfeeding, donor milk, milk banking, Norway, preterm infants

Norway has a population of 4.5 million and about

60000 deliveries every year. There are 55 birthing units
across the country, and many are small local ones. There
are 21 neonatal intensive care units (NICUs), located in
19 counties, which care for preterm and sick newborns.
Between 1993 and 1996, 70% to 80% of all infants
were born in Baby-Friendly hospitals. Today 90% of
babies are born in a Baby-Friendly facility. The BabyFriendly status for the hospitals was reassessed for the
first time after 10 years in 2005. Now there is an annual
registration that does not require a full reassessment but
does require review of practices. Currently 67% of the
21 NICUs are also designated Baby-Friendly.
Breastfeeding Practices in Norway

Before and during the Second World War (19391945) almost every Norwegian child was breastfed.
After the war the breastfeeding incidence decreased.1
With increasing hospital deliveries, scheduled feeding,
and more availability of formula, the numbers of
breastfed babies decreased. In the 1960s only 20% of
Received for review October 19, 2007; revised manuscript accepted for
publication February 1, 2009.
Anne Hagen Grvslien is a breastfeeding consultant and since 1995 has
managed the milk bank at the Department of Pediatrics, Rikshospitalet
University Hospital, Norway. Morten Grnn, MD, PhD, is with the Depart
ment of Pediatrics, Neonatal Unit, Rikshospitalet University Hospital,
Norway.
Address correspondence to Anne Grovslien, Department of Pediatrics,
Rikshospitalet University Hospital, 0027 Oslo, Norway; e-mail: anne.
hagen.grovslien@rikshospitalet.no.
J Hum Lact 25(2), 2009
DOI: 10.1177/0890334409333425
Copyright 2009 International Lactation Consultant Association

mothers were still breastfeeding their babies 3 months

after delivery. Formula feeding was recommended to
mothers with breastfeeding problems.
By the early 1970s breastfeeding rates were increasing again. Figure 1 shows all breastfeeding, not exclusive breastfeeding. The interest in breastfeeding
increased as better information and help became accessible, and, most important, new routines on the maternity wards made breastfeeding again possible for the
mothers. Today, rooming-in, feeding soon after birth,
and infant-led feeding, including at night, are practiced
in all hospitals.
The latest national statistics2 show 99% breastfeeding
initiation and 44% exclusive breastfeeding at 4 months.
However, by 6 months, although 80% of babies are still
breastfeeding, only 7% are exclusively breastfed. At 12
months, 36% continue to breastfed along with complementary feeding.2
The Norwegian breastfeeding support organization
Ammehjelpen deserves a great deal of credit for this
change. This group continues to actively educate and help
both health care workers and mothers and parents. One of
the issues in Norway has been breastfeeding in public,
which has generated much public debate. Today there is
no problem with breastfeeding almost anywhere at any
time. A mother might get an ugly glance once in a while,
but restaurants, shopping centers, and even government
offices allow breastfeeding without any discussion.
Maternity leave has increased gradually as the
breastfeeding rate has increased. Today a mother can
stay home for 12 months with 80% of her usual income
or for 10 months with 100% income. Mothers also
have the right to take time off to breastfeed when they
go back to work.

206
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J Hum Lact 25(2), 2009

Milk Banking in Norway

207

Percentage breastfeeding mothers

Breastfeeding in Norway 1860-1998

100

80

60

40

20

0
1858

1868

1878

1888

1898

1908

1918

1928

1938

1948

1958

1968

1978

1988

1998

Year of birth

1 week

3 months

6 months

9 months

12 months

18 months

Figure 1. Breastfeeding in Norway 1860 to 1998. The graph is based on data collected and interpreted by Dr Margit Rosenberg in 1991, in
connection with her doctoral thesis: Rosenberg M. On the Relation Between Living Conditions and Variables Linked to Reproduction in
Norway 1860-1984 [doctoral dissertation]. Oslo, Norway: Department of Informatics, University of Oslo; 1991. The data series was originally
published in: Liestl K, Rosenberg M, Walle L. Breast-feeding practice in Norway 1860-1984. J Biosoc Sci. 1988;20:45-58. The data series
was later adjusted by Dr Elisabet Helsing in collaboration with the author in order to add more recent comparable data from the period after
1984.3

Norwegian national guidelines for infant feeding

published in 20014 state that babies should be fed only
with human milk for the first 6 months. Breastfeeding
should continue for the whole first year, and solid
foods are introduced gradually after the first 6 months
of life. The regulations specify that if breast milk is not
available in the first year, the baby should be fed infant
formula. The guidelines also state that a few babies
will need to start solid food earlier than 6 months but
never earlier than 4 months.
Donor Milk Banks

Milk banking in Norway has a long tradition of

using raw milk. It requires a strict control and screening
of donors. A high breastfeeding rate affects the amount
of milk available in the milk banks, and all the preterm
babies are offered donor milk if the mothers own milk
is not available or the supply is insufficient. We have a
program of active and early nutrition support for
preterm infants to avoid malnutrition.
There are still some differences among the Norwegian
milk banks but in general they are operated similarly.
History of the Norwegian Donor Milk Banks

The first donor milk bank in Norway was opened by

the Germans in 1941 during the Second World War. It

has moved a few times and is now located at Ullevl

University Hospital in Oslo. Around 1990 the interest
in donor milk banks increased, and in 1997 there were
17 active donor milk banks. Today there are 13 donor
milk banks, all located in and operated by hospitals
with level III NICUs.
Guidelines for the Milk Banks

In 2002 the Norwegian National Board of Health

published guidelines5 for the operation of donor milk
banks. The guidelines state that human milk is both
biologically active tissue and nutritional support. The
guidelines define the organizational structure of the
milk banks, what equipment is to be used and how it
must be maintained, donor qualifications and exclusion
criteria, and procedures for screening, handling, and
dispensing the milk. Donor milk banking in Norway is
still based on the long tradition of using raw, unpasteurized
milk for the premature infant. Only 1 milk bank in
Norway pasteurizes all donor milk and uses the milk for
preterm babies less than 1500 g. Norway continues to
have a low incidence of necrotizing enterocolitis and
late-onset sepsis.6
One issue that we are looking into is the risk of cytomegalovirus (CMV) transmission via milk for the
extremely premature infant. At Rikshospitalet University

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208

Grvslien, Grnn

Hospital we are considering pasteurization to deactivate

CMV in the milk for these infants. However, with larger
and term babies there are so far no plans to change our
practices.
The use of raw milk is reasonable in a country such
as Norway with a very low incidence of HIV and hepatitis and a high standard of living, where donors can be
retested frequently.7
All donors go through an extensive screening process
to rule out any risk factors for disease and every third
month are given a blood test for HIV, hepatitis B and C,
CMV, and human T-cell leukemia virus (HTLV) 1 and
2. To date, there has not been a positive test result when
retesting an approved donor at our hospital.
The criteria for becoming a donor can seem difficult, but we usually have no problem recruiting enough
donors. Norwegians in general, and donors suitable for
milk banks in particular, are not a high-risk group for
any of these diseases; however, the issue of using raw
donor milk is constantly under discussion.
All milk banks must have a system for tracing the
milk from the donor to the recipient and from each
recipient back to the donor, just like a blood bank.
However, the anonymity of both the donor and the
recipient is always maintained.
A few banks sell milk to other hospitals, but mostly
they provide their own neonatal unit and in some cases
other units within the hospital. Babies who are not
hospitalized are not a prioritized group for receiving
donor milk in Norway. However, there have been a
few cases where milk was provided to a baby at home
for a fee. For example, a baby with an HIV-positive
mother and a baby with allergies whose mother had
cancer were provided with donor milk after hospital
discharge. They had all been treated at the hospital and
the doctor asked whether we could provide them with
milk for a few weeks. No prescription is required in
such cases, but typically milk banks do not dispense
milk to outpatients not treated by the hospital.
The 2002 national milk bank guidelines also state
that parents should be informed of the option to use
donor milk for their sick newborn babies. Information
must include our excellent track record with using
donor milk from healthy Norwegian women and the
risk of using nonhuman milk alternatives.
Rikshospitalet Donor Milk Bank

Rikshospitalet University Hospital has about 2000

deliveries every year and a neonatal unit with 22 beds.

J Hum Lact 25(2), 2009

Figure 2. Milk ready for use.

The NICU is a regional referral center, and 20% of the

premature babies in Norway (< 1500 g) spend their
first weeks here. The hospital is located close to the
capital center, Oslo, and in a densely populated area.
At our hospital no milk is pasteurized. Each 500-mL
container of milk from a donor is screened for bacteria.
Milk that contains any pathogens or high bacterial
count (> 100000 colony-forming units/mL) of any
other bacteria is destroyed. Milk with a low bacteria
count (< 10000 colony-forming units/mL) is used for
the smallest preterm babies (Figures 2 and 3).
Rikshospitalet University Hospital has 40 to 60
donors each year, mostly recruited outside the hospital.
Some donors have given more than 400 L of milk, but
the average is 30 L. In recent years the total amount of
milk collected at Rikshospitalet has been 1000 to 1100
L per year. The donors usually donate for 6 months and
are offered use of a hospital-grade pump for free. The
milk bank gives donors a small compensation of 150
NOK per liter, or about $20 US per liter, to cover electricity and travel expenses such as parking and toll
roads. Compensation for donors varies. Some milk

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J Hum Lact 25(2), 2009

Milk Banking in Norway

209

Late-Onset Septicemia of Extremely

Premature Infants Receiving Very Early
Full Human Milk Feeding

Figure 3. Testing the milk for bacteria.

banks do not compensate their donors. The national

guidelines say that payment for the milk is not allowed
but that the donor can be compensated for actual
expenses she has incurred. There is a charge of 650
NOK, or $100 US, per liter for milk dispensed to other
hospitals.
At our hospital all babies who may need milk from
the bank are offered it. Sometimes this is a healthy
baby whose mother cannot breastfeed while she is in
the hospital. We work closely with the NICU and the
nutrition unit and give lactation support to the mothers
of the NICU babies.
Guidelines for Nutritional Support in the
NICU at Rikshospitalet

To avoid postnatal malnutrition, we have active and

early nutrition support for all preterm infants. All
babies who need parenteral nutrition will start with
protein (2 g/kg/d) and lipid solution (0.5-1.0 g/kg/d) in
the first days of life. Carbohydrate infusion is
maintained at a minimum level of 8.5 g/kg/d. Insulin
infusion is now more frequently used to regulate the
blood sugar. Minimal enteral feeding with human
milk, either from the mother or from the milk bank, is
started on the first day of life. All babies who have an
intact digestive system, regardless of gestational age or
other malformations or diseases, will start enteral
feeding with human milk (0.5-1.0 mL/kg/h). In some
babies with severe asphyxia, the start and progression
of enteral feeding will be slower. Human milk fortifier
is added from day 7 if tolerated.

A prospective study was done by Rnnestad et al6 of

all infants born in Norway in 1999 and 2000 at less
than 28 weeks gestation or with a birth weight of less
than 1000 g. Extensive clinical information, including
data on feeding practices and episodes of septicemia,
was collected. The study showed that very early enteral
feeding with human milk, achieving 150 to 200 mL/
kg/d by the second week of life, reduced the risk of
late-onset septicemia by nearly 4-fold among these
extremely premature infants. The overall most
influential risk factor for late-onset septicemia was the
number of days without establishment of full enteral
feeding with human milk. The study also showed that
very early feeding with human milk is possible at a
much earlier age than commonly reported. Enteral
feeding with human milk was initiated within the third
day for 98% of patients, and 92% were receiving full
enteral feeding with human milk by the third week.
This is the current practice in Norway but is dependent
on the availability of human milk from the mother or
the milk bank.
Summary

Breastfeeding initiation in Norway is 99%, but for

the babies who weigh less than 1500 g and whose
mothers cannot supply milk, there is a network of
donor milk banks that are part of the national health
system. Milk banking in Norway goes back to 1941.
All donors are carefully screened, and most milk is
dispensed raw, rather than pasteurized.
For the future we hope to continue our long practice
with using raw milk. Good guidelines and an active
milk bank association will ensure that that every baby,
no matter where he or she is born in Norway, is offered
milk from the banks if needed and wanted. We can
thank our breastfeeding mothers for a good supply of
milk to the banks.
Acknowledgments

We thank Mary Rose Tully for the help with this

manuscript.
References
1. Liestl K, Rosenberg M, Walle L. Breast-feeding practice in Norway
1860-1984. J Biosoc Sci. 1988;20:45-58.

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210

Grvslien, Grnn

2. Lande B, Andersen LF, Brug A, et al. Infant feeding practices and

associated factors in the first six months of life: the Infant Nutrition
Survey. Acta Paediatr. 2003;92:152-161.
3. Rosenberg M. On the Relation Between Living Conditions and
Variables Linked to Reproduction in Norway 1860-1984 [doctoral dissertation]. Oslo, Norway: Department of Informatics, University of
Oslo; 1991. (Data from 1984-1998 added by Dr E. Helsing in collaboration with Rosenberg)
4. Directorate for Health and Social Affairs. Recommendations for Infant
Nutrition. Olso, Norway: Directorate for Health and Social Affairs;
2001. Norwegian Publication, 2001-IS-1019.

J Hum Lact 25(2), 2009

5. National Board of Health. Guidelines for Milk Banks. Olso, Norway:

National Board of Health; 2002. Norwegian Publication 2002-IK2760.
6. Rnnestad A, Abrahamsen TG, Medbo S, et al. Late-onset septicemia in a Norwegian national cohort of extremely premature infants
receiving very early full human milk feeding. Pediatrics. 2005;115:
e269-e276.
7. Lindemann PC, Foshaugen I, Lindemann R. Characteristics of breast
milk and serology of women donating breast milk to a milk bank. Arch
Dis Child Fetal Neonatal Ed. 2004;89:F440-F441.

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