Who should get donor milk? Who should it be offered to?

Dou-la-la's post on encouraging the informed milk use of donor milk over formula supplementation got me thinking. At the hospital where I work, I have a lot of parents ask me about supplementation. They want to do los dos from the beginning, or they believe that the mother's colostrum isn't sufficient, or they're concerned that the fussy baby who wants to nurse constantly is starving, or they're tired of the fussy baby nursing constantly and just want to sleep. If they're really set on it, I encourage them to supplement at the breast vs. with a bottle, and not to give too much. If they're considering it but haven't decided yet, I do my best to educate them about risks of supplementation, including compromising future milk supply and altering the baby's gut. But in the end, it's their baby and their choice if they want to supplement.

Sometimes, I have to tell parents - even parents who don't particularly want to hear it - that we need to supplement. Because their baby has lost too much weight, or because there are latch difficulties, or because there is persistent hypoglycemia not helped by just direct breastfeeding. We do our best to supplement with only the mom's own expressed milk, but sometimes we have trouble getting enough of it out. In the end, those parents have to supplement - it's a medical necessity.

The thing is, no one at our hospital actually has to supplement with formula. We have banked, pasteurized human milk available for our NICU babies, and the term babies can access it as well if the parent requests it and gets a physician order. We don't need to ration it; the milk bank will tell us if they're running low and will ration appropriately on their own. We can offer it to anyone we want and they can use as much as they need while they're in the hospital, with the cost covered completely by the hospital, regardless of their insurance (or lack thereof). But once they go home, they have to purchase it from the milk bank directly themselves (unless they can convince their insurance provider to reimburse) or they have to find donor milk through other, less formal channels (as Dou-la-la discusses).

The other day one the nurses made an observation to me about who she usually sees using donor milk and who she doesn't. She asked if we offered it to everybody or if there was some discrimination going on. It got me thinking about it, and I talked to one of the other LCs about who gets offered donor milk and who should get offered donor milk. We had fairly similar feelings about it, but I won't say right now what we thought. I would like to ask all of you.

Since there's now a fairly active blogosphere conversation about donor milk being the ideal supplement for babies who are not being fully breastfed by their mothers for whatever reason: Who should be offered donor milk when the decision to supplement arises - for personal or medical reasons - and who should not? Why?

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