NC works to expand availability of donor breast milk as demand rises

By Rachel Crumpler

Demand for pasteurized donor breast milk is rising.

More than 10 percent of babies born in North Carolina are premature, according to state data. In 2023, that meant 12,885 premature infants. Breast milk helps protect premature babies’ guts and helps facilitate their growth.

The increased demand is due to growing recognition of the health benefits, as well as an uptick in premature infants in North Carolina receiving the milk. 

When a mother’s own breast milk isn’t available the American Academy of Pediatrics and Centers for Disease Control and Prevention say pasteurized donor milk is the best alternative — better than formula. In particular, that’s because human donor milk can dramatically reduce the risk of necrotizing enterocolitis — a serious and even fatal gastrointestinal disease that destroys the lining of a newborn’s intestinal walls.

Pasteurized human donor milk can also bridge the gap until a mother’s milk supply comes in, promoting longer exclusive breastfeeding. And it turns out that the process of quickly pasteurizing breast milk works well to destroy harmful viruses, like HIV, while only minimally altering the nutritional components that protect babies. 

Efforts are underway in North Carolina to bolster the supply and availability of donor milk across the state and expand the number of hospitals offering the milk to medically fragile infants. 

40 years of milk banking in NC

WakeMed’s Mothers’ Milk Bank in Cary is the only human milk bank in North Carolina accredited by the Human Milk Banking Association of North America. The milk bank has operated since 1985 and is just one of 32 nonprofit milk banks in the United States.

Every month, the milk bank collects thousands of ounces of breast milk from voluntary donors across the state. After pasteurizing it, the milk bank dispenses the donor milk — mostly to about 44 neonatal intensive care units across the state and the Southeast. In fiscal year 2024, the milk bank distributed 306,709 ounces or approximately 2,396 gallons — an increase of 56,243 ounces or more than 439 gallons from fiscal year 2023. 

To put that amount in perspective, one gallon of donor human milk can nourish 31 infants for a single day — or sustain one premature infant for an entire month, said Courtney Ramsey-Coleman, who leads an initiative at the N.C. Department of Health and Human Services to improve access to donor milk and improve breastfeeding rates.

Kerrie Gottschall, manager of Mothers’ Milk Bank, said the bank is on track to distribute even more donor milk this year.

“We’ve seen a lot of increased orders with our NICUs locally and out of state. It seems like right now the NICUs are really busy,” she said. “We’re actually dispensing more milk this time of year than this time last year, so we’re always trying to have more donors.”

Last year, in partnership with DHHS, Mothers’ Milk Bank opened five new depots across the state where donors can drop off breast milk. The sites have collected 250 gallons of milk to date, Ramsey-Coleman said.

“The goal is to ensure that no medically fragile infants are denied access to [donor milk] based on geography, income or awareness, so really making this a known and open thing just like formula is,” Ramsey-Coleman said. 

Standard of care

Gottschall, who worked for years as a NICU nurse, said pasteurized human donor milk provides premature infants with the best outcomes. She watched this up close as she took care of preemies — and saw the potential consequences of skipping to formula. 

A tragedy early in her career, around 2006, still sticks with her. Gottschall said she left her shift thinking the 34-week-old premature infant she had been taking care of was getting stronger and healthier. But the next day, she found that the baby had developed necrotizing enterocolitis, which would turn fatal.

“He went to surgery overnight, and his gut had completely gone dead,” Gottschall recalled. “There was nothing we could do but bring him back up for his parents to hold him.

“For them, it was a language barrier,” she recalled. “We offered donor milk. They said, ‘No, they would prefer to use formula because they had other children they had used formula with previously,’ and we accepted that.” 

But in hindsight she said they should have communicated better the importance of donor milk and how risky formula can be for the developing gut. Donor human milk reduces the risk of developing necrotizing enterocolitis by about 50 percent in preterm or low birth weight infants compared to formula feeding, according to a study published last year.

The case sparked Gottschall’s passion “for feeding a baby the right way every time” — a path she’s been on for the past two decades, including the past three years as manager of Mothers’ Milk Bank. More people are starting to understand the importance of donor milk, she said, but there’s still work to do.

“It really should be the standard of care for infants who are born premature to get either mother’s own milk, or if that’s not available, then to use donor milk instead of formula,” Ramsey-Coleman said.

What is donor milk and where does it come from?

Milk banks collect donations from nursing mothers who are producing more breast milk than their babies need; all the mothers are screened for eligibility based on health and lifestyle factors. The milk banks then process and pasteurize the milk to ensure its safety and nutritional content before distributing it.

Mothers’ Milk Bank needs 300 to 350 active donors each month spread from the mountains to the coast to donate their extra breast milk to maintain its pool of donor milk. Some are one-time donors who clean out their surplus of frozen breast milk. Others give on a more regular basis throughout the period they’re still breastfeeding. 

“We have a lot of donors who are giving back because they’ve received the milk in the hospital,” Gottschall said. “Knowing that other mothers wanted to give back to them and be able to provide nutrition to their baby was life-changing, so a lot of our donors will give back.”

Notably, about 10 percent of donors are bereaved mothers who opt to pump breast milk in honor of their child, Gottschall said.

Maryanne Perrin, a nutrition professor at UNC Greensboro who studies donor milk, said milk banking has been around for more than 100 years, though she said it’s more recently been in a period of “renaissance” and growth.

The Human Milk Banking Association of North America’s network of 32 milk banks dispensed a record-high 11 million ounces of pasteurized donor human milk in 2024 — a 10 percent increase from 2023, according to a February 2025 news release. 

Compared to other critical donations like blood and organs, milk banking is not very well-known. That can lead to some skepticism, Perrin said.

Ramsey-Holland has heard such uncertainty when promoting the benefits of donor milk in communities.

“A lot of people are scared because that’s fluids from another person’s body,” she said. “Formula has had the advantage for a really long time, but we’re trying to make people more aware about the safety around donor milk.”

Perrin is active in policy efforts to promote safe practices in donor milk banking. She was appointed in 2022 to be one of 16 members and co-chairperson of the World Health Organization’s Guideline Development Group for establishing and implementing safe and quality human milk banking systems. 

Perrin explained that screening for breast milk donation was modeled after blood donation, involving a medical and lifestyle history to ensure the safety of the donated product. Additionally, milk banks in the United States are regulated and inspected as food manufacturers by the U.S. Food and Drug Administration and their local health departments.

Even with all the rigorous safety protocols, including pasteurization to eliminate viruses and bacteria, Gottschall said Mothers’ Milk Bank staff run tests on milk samples every day to ensure quality. 

“Every pool of milk that we make, we’re taking a nutritional sample of it and analyzing it, and we’re only providing NICUs with the gold standard, which is 20 calories [per ounce] or higher,” Gottschall said.

Understanding donor milk

Perrin said there’s long been a misconception, even among medical professionals, that all breast milk is the same — and that donor milk is the same as a mother’s own breast milk. 

“They’re not nearly as close as people want to think,” Perrin said. “They’re both human milk, and so people think they’re like sisters. But they’re like second or third cousins in my mind.”

Her research diving into the composition of human donor milk is revealing just how variable milk can be from person to person and based on milk banking practices. 

Funded by a $1.4 million federal grant from the National Institute of Child Health and Human Development, Perrin collected 600 samples of donor milk from eight milk banks from around the world — including the United States, Kenya and Poland — and is comparing their compositions.

“Donor milk or human milk has nutrients, but it’s also chock full of these bioactive molecules, and that’s where I say the secret sauce is — that’s not what you’re going to find in infant formula,” Perrin said. “Antimicrobial proteins can bind up bacteria and prevent them from getting into the infant’s blood supply. It has enzymes to help the infant digest the milk. It has white blood cells, and it has stem cells … It’s just this very dynamic biofluid.”

While her findings have yet to be published, she said mothers’ genetic differences contribute to some variations in breast milk. Timing of the donation also plays a role.

“Seven of the milk banks look one way and one looks a different way on almost every nutrient,” Perrin explained. “The seven were milk banks that mostly recruit women who gave birth at term, and they’re now three months postpartum.”

The last milk bank recruited women about a week after they gave birth, mostly to preterm infants.

Now that Perrin has characterized the variability in donor milk, she’s turned to computer modeling to determine if there are ways milk banks can create a more consistent product full of the rich macro and micronutrients that best help premature infants be nourished and grow.

“We have enough strong data that says if we use donor milk, we will not hurt their gut like we do when we use infant formula,” Perrin said. “Now, the challenge is how do we make a better donor milk or a better clinical practice for using donor milk so that we get better growth?”

Expanding access points

While donor milk is primarily used in NICUs, there are benefits to having it available in outpatient settings, Ramsey-Coleman said. North Carolina is looking to expand those options — with the aim of improving breastfeeding duration rates.

In 2024, 82.8 percent of infants born in North Carolina were being breastfed at discharge from the hospital, according to data from the N.C. State Center for Health Statistics. Just under half of infants in North Carolina were exclusively breastfed during their first three months, with the rate dropping to about 28 percent of infants being exclusively breastfed through six months, according to the latest CDC breastfeeding data from 2021.

Currently, there is only one outpatient distribution site in North Carolina where donor milk is available by prescription: 501 Pharmacy in Chapel Hill. Ramsey-Coleman said DHHS is actively working to expand outpatient access with the goal of establishing another outpatient distribution center by October. While a location has not yet been selected, Ramsey-Coleman said that they are looking to pair the outpatient distribution with a lactation center so that a mother can get help building her own milk supply while using the donor milk as a short-term supplement.

“Donor milk is very precious, and it’s a very limited resource, so it’s not something that people can use long term,” Ramsey-Coleman said. “We really want it just to be an aid to building [the mothers’] milk supply. As they’re building up that supply, they can supplement a little bit with the donor milk and then the goal would be to go back to exclusively breastfeeding.” 

Additionally, Ramsey-Coleman said the state’s ability to open outpatient donor milk distribution centers will be dependent on the state’s supply of donor milk — contingent upon the volume of voluntary donations. 

NICUs will always be the first priority for receiving donor milk, Ramsey-Coleman said. But with additional donors, more supply could likely be allocated for outpatient use, though in North Carolina donor milk is self-pay and not covered by Medicaid or private insurance. That could be financially prohibitive for some, she added.

“We’re always encouraging the public, if they have extra milk, to reach out to us, because we’re trying to always stay ahead of the curve of need,” Gottschall said.

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