Maximising the public health impact of a human milk bank

Human milk is hugely complex, containing thousands of factors that guide development, protect babies from infections, and train their immune system to recognise harms. Breastfeeding also gives major health benefits to mothers, but these are largely unknown and unexplained. Furthermore, human milk banks, which provide screened donated breast milk to sick infants when a mother's milk supply is insufficient, have been restricted in recent decades, meaning donor milk is now rationed to only the most preterm babies.

The UK has no dedicated centre of research into human milk, and few centres in the world focus on the maternal health impact of breastfeeding. Having founded the first independent non-profit human milk in the UK 2 years ago, I have laid the groundwork to launch an innovative programme of three research projects, each of which will lay the foundations for a larger body of impactful research and clinical advances. The three projects are summarised:

1: Genetic mutations are known to cause breast cancer (e.g. BRCA1 mutations), but much less is known about the epigenetic risk. Epigenetics describes the modifications to DNA that regulate how much of the DNA is turned into proteins. Epigenetic patterns are tissue-specific, so patterns detected in breast cells are different to other tissues such as blood. Previous research, including our own work, has identified epigenetic patterns of breast cancer risk in the DNA of blood DNA. We have found evidence that different cancer risk factors, such as smoking, alcohol and BMI, influence these patterns. However, it is difficult to extrapolate these findings to breast tissue. Breast milk contains a large number of cells from the lining of the breast ducts that are the same cell type that may develop breast cancer. Many of the molecular changes that cause breast cancer may occur long before the cancer has developed and may be detectable in these cells. First, I will recruit more subjects into our research cohort to reach a minimum of 300 subjects. We will assess known epigenetic markers of risk including aging, smoking, alcohol and BMI. This project will provide evidence of early changes in normal breast cells and provide important biological insights into how these increase risk. Finally, this work will provide the evidence needed to create a large study of milk from 20,000 women to develop new cancer screening tests.

2: The World Health Organisation recommends children are breastfed for at least 2 years, but only tiny amounts of data exists on the composition of human milk beyond 6 months. We will recruit 45 mothers to give samples of milk every 3 months over at least 2 years, and profile each sample for the 1000s of fatty acids to understand how milk composition changes, if at all. This information will guide milk donor recruitment, address the value of breastfeeding beyond 6 months, and inform future studies of targeting donor milk for babies with specific nutritional needs.

3: Babies born just a few weeks prematurely, so-called late preterm babies, have a higher risk of death and ill health than full-term babies. They are often a good weight and mostly do not need help with breathing, but still have subtle problems. One of these problems is a lower chance of establishing breastfeeding. Extremely premature babies who receive only mother's milk or donor milk do better in both the short- and long term compared to those who receive formula. Mothers whose babies receive donor milk see it as a 'bridge' to expressing or breastfeeding. We will recruit 120 babies and mothers born late preterm and randomise them to receive donor milk compared to formula with lactation support to assess whether this helps mothers to establish breastfeeding.

The three questions addressed in this Fellowship aim to help improve the UK's breastfeeding rates, which have been among the worst in the world for more than two decades. This Fellowship presents a unique opportunity to drive change.

Academically, this research fits well within a growing body of interdisciplinary maternal and infant health research relevant to researchers in academia, public health and policy, and across multiple scientific and medical fields, including oncology, clinical genetics, paediatrics, midwifery, public health, nutrition, nursing, microbiology and policy. It will enhance current networks that I established over the course of my bench-based science career and strengthened since establishing the Hearts Milk Bank, and lead to new international collaborations. Findings will be disseminated in leading cross-disciplinary journals and at international conferences.

The combination of research is strongly translational with significant real-world impact for health professionals in multiple sectors and the families they support. The findings from this programme have the potential to change policy and practice, leading to increased breastfeeding rates, reduced rates of maternal breast cancer and more babies and families benefitting from receiving screened donor human milk (DHM), as well as a greater public understanding on the broader maternal health impacts of breastfeeding. In accordance with my work over the last 2 years, I will therefore extend the reach of this work to a far wider audience globally than can be reached via academic publications. From this start, I will ensure that the studies are relevant and feasible for those affected by involving health professionals, parents and policy makers in project-specific advisory group (working with Bliss, HuMBAG and the IPPV), asking for their support in developing our research tools. We will present our findings to them, again asking for their support in helping the optimal dissemination.

Furthermore, findings will be of relevance to:

1) Health professionals and students, engaged through conference and study day talks, university lectures, articles for professional publications and the design of educational and CPD material.

2) Charities and organisations supporting breastfeeding and families by speaking at study days and events and writing blogs and magazine material. I will work closely with the Baby Friendly Initiative, Breastfeeding Network, and UK and international milk banking associations (EMBA and HMBANA) to achieve this.

3) Mothers, infants and families through using social media, parenting forums podcasts (e.g., Parenting Science Gang, iLactation, etc.), parenting blogs and develop animations for broad dissemination, including through a project-specific website.

4) The general public through recognising the impact of wider public knowledge and attitudes and ensuring our messages are relevant to all, not simply those who are going through the experience. I will continue to work with the community interest company 'Tiny Humans CIC' and contacts made in the last year (Nesta, Cambridge Social Ventures, White October, Economist films) to create short films around the links between breastfeeding and cancer risk, and the impact of DHM use.

5) Policy makers through policy briefings, presentations to APPGs, select committees, etc.

Throughout the Fellowship, I will engage with the media through press releases, interviews for newspapers, television, internet and radio, while working with the relevant public advisory groups to determine and cocreate the key messages.

Pathways to impact will be enhanced by ensuring the findings reach those who matter and can be used, where appropriate, to influence policy and practice, and enhanced by the strengthening of local and international collaborative networks.