Ruth goes home: an adult's use of human milk.
Cancer patients (Health aspects)
Gastrointestinal cancer (Care and treatment)
|Publication:||Name: Breastfeeding Review Publisher: Australian Breastfeeding Association Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2012 Australian Breastfeeding Association ISSN: 0729-2759|
|Issue:||Date: Nov, 2012 Source Volume: 20 Source Issue: 3|
|Topic:||NamedWork: Snapshots from Our Lives (Nonfiction work)|
|Geographic:||Geographic Scope: Australia Geographic Code: 8AUST Australia|
'Ruth goes home' is the account of a woman with terminal
bowel cancer who found that donated breastmilk helped her gain the
strength to travel home. Ruth's experience raises questions about
how human milk might have been beneficial. Those questions are addressed
later in the paper but first, Helen Gardner tells Ruth's story in
an extract from the book Snapshots from our lives.
I met Ruth through the B'nai B'rith* Environment Group (BBEG). She was an American who came here [Melbourne, Australia] with her husband and had been here for about 6 years when we first met. I first learned that she had cancer in late 2002 when I picked her up to go to a meeting. I thought she looked very thin and drawn. When I asked her just as a routine question how she was, she made some remark about feeling the cold very badly because of the chemotherapy. She wanted to go home.
I saw her intermittently in 2003, and in early June I received an email saying chemo had ceased to be effective, and that she was going back to the States for further treatment within 4 weeks. She had planned a potlatch to give away her goods before they left, but on the day the hostess was not there. She had been admitted to Cabrini Hospital the day before.
The next I heard, she was leaving on 8 August and there was to be a farewell party for her on 3 August, but once again, on the day the guest of honour was not there. She was back in Cabrini. She looked bad. Eating was painful and took a long time to ease. Her doctor had given her 2 weeks to live if she stayed in Australia. I thought she was dying, and so did she. She told me she did not think she was going to make it to catch the plane.
The day before she was due to leave I went to say goodbye. Her bowel blockage had eased and she looked a little better. She was determined to get on that plane the next day, and was busy investigating things she could eat and drink which would enable her to stay hydrated during the trip. One of her visitors suggested breast milk, and another, a nursing mother, provided some to try. It was an instant success. Ruth made arrangements to leave the hospital by 8 am next morning and arranged for a wheelchair to be waiting at the airport. And so the quest began. Where to get Ruth enough breast milk to get her through the trip?
Some members of the Australian Breastfeeding Association (ABA) were contacted informally [see ABA policy next page], but the majority of contacts came through a young friend of mine, 37 weeks pregnant herself at that time, who is very involved with the ABA and who got on the phone immediately. I contacted my daughter who was also nursing, and she contacted a couple of friends. By 8 pm that evening I was out on 'the milk run' through Oakleigh, Glen Iris, North Fitzroy and Fairfield, aiming to deliver enough milk that evening for the planned 8 am start the next morning.
Meanwhile, Ruth's doctor, confronted with her determination to leave, decided she was not well enough to take an ordinary flight, but that he could arrange for a 'medical evacuation, meaning that she would travel on a stretcher with a drip, an oxygen supply, and a doctor and nurse in attendance. This was expected to take 5 to 7 days to organise, and our initial plans to collect enough milk to last Ruth for the flight were transformed into collecting enough milk to keep her alive for a week or so, plus enough frozen milk to last a few days once she arrived home.
This we did!
My young friend and her mother concentrated on collecting in the Kew/ Ivanhoe region. With magnificent help from Hatzolah** and other friends in the orthodox community, I focused on Caulfield. With contributions coming in from many people who had heard about the need, we collected over 12 litres of milk, (fresh and frozen)--a magnificent effort. A prayer group was also initiated by those connected with Hatzolah.
Ruth improved remarkably on the breast milk. Her digestive system was able to utilise the milk, and within a few days she was able to eat small amounts of baby rice cereal and stewed apple. By 13 August she was off the drip and sitting out of bed for short periods. By the time she flew home on 16 August, she no longer needed a stretcher and was able to travel first class, using the lay-back seats as a bed. During the stopover in Los Angeles she visited with an aunt and uncle and a very good friend.
It took about 25 hours from the time of leaving Cabrini to arrival at the hospital in the city where her mother lives. The flight was trouble free. Ruth arrived in far better condition than we had ever hoped for. After a short stay in hospice care she went home to her mother, who had offered to look after her. She died peacefully 15 days after returning home.
Saving Ruth's life was never part of the plan, although we probably all hoped that we could. We set out to get her home to see her family, and achieving that was a little miracle in which we all took part, and which could not have happened without the combined efforts of all of us.
For my part, this experience, while somewhat bizarre, was wonderfully rewarding. The outpouring of care, concern and prayer for a stranger was deeply touching. Ruth was several times in tears as she expressed her gratitude to the many people whose milk was keeping her alive. If we blessed Ruth with the gift of going home, she blessed us with the opportunity to reach beyond ourselves, to join with others, many unknown, and to experience goodness in the world. In the end, we offered Ruth far more than milk, and she offered us the rare mitzvah*** of caring for another without thought of return.
Before Ruth began drinking breastmilk she was receiving fluids in an intravenous drip. Obviously Ruth needed hydration and nutrition, but eating was painful. After a few days of taking breastmilk, she was able to have her intravenous line removed and to eat small amounts of semi-solid food. She must have been well enough hydrated and nourished to manage without parenteral nutrition. Ruth attributed her improvement to the breastmilk. How could breastmilk achieve that, if other foods did not? There have been no controlled studies of human milk's effects in adults with cancer, but breastmilk is well known to affect infant health. Breastmilk has anti-inflammatory and antioxidant properties as well as providing species-appropriate nutrition. Some breastmilk components have been identified as being able to kill cancer cells without affecting healthy cells. Perhaps some of these properties might be useful to cancer patients, as well as to infants? What follows is unavoidably speculative and limited to generalities. It aims only to illustrate the biological plausibility of breastmilk's use as a complement to conventional medical treatments.
Breastmilk is easily digestible
Breastmilk has an osmolality similar to that of serum, that is, the concentration of dissolved salts and glucose (osmotically active solutes) is similar to that of serum. This means the dissolved nutrients and water from breastmilk can easily cross the gut wall and do not draw water into the gut. Iso-osmolality is one of the features that makes breastmilk suitable for people with damaged gut lining, such as that which occurs after chemotherapy. However, if lactose is not digested in the small intestine because gut damage (or normal ageing) has reduced the amount of lactase present, it may be digested by bacteria in the lower bowel and draw water into the lower bowel causing discomfort and diarrhoea. Given that Ruth's story does not record any such distressing symptoms, she was probably able to digest the lactose.
Human milk fats are particularly suitable for digestion and absorption (Innis 2011). This is important in infants since they have less efficient fat absorption than adults, but it may also be valuable to a person with cancer. Glucose tolerance can be impaired in cancer patients, so the European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines suggest 'lipids might be the preferred substrate' for cancer patients (Arends et al 2006). Studies comparing infant absorption of different fats have shown that human infants absorb fats very efficiently from breastmilk Triglycerides consist of a glycerol backbone with three fatty acid chains extending from the backbone. In the process of digestion, lipase removes the two outer fatty acids, leaving the central fatty acid still attached to the glycerol backbone. Studies comparing infant absorption of different fats have shown that human infants absorb long chain fats and calcium more efficiently with that arrangement (Carnielli et al 1996). Early formulas had a tendency to form calcium soaps in the infant gut, resulting in hard stools because the fats were not efficiently absorbed (Innis 2011). The damaged gut, post chemotherapy, might also benefit from human milk's arrangement of fatty acids Breastmilk proteins provide a balanced source of amino acids and many have bioactivity in the gut: antibacterial activity (lactoferrin, lysozyme); mineral binding (lactoferrin, alpha-lactalbumin); and enhancement of vitamin absorption (haptocorrin, folate binding protein) (Lonnerdal 2010). These factors and the presence in breastmilk of digestive enzymes such as lipase, would be expected to maximise the absorption of breastmilk nutrients. Breastmilk contains bile salt-stimulated lipase which may begin the process of digestion of the milk fats (Lonnerdal 2010; Innis 2011). Chemotherapy kills not only cancer cells, but any actively reproducing cells in the body and the cells lining the gut are included So after chemotherapy, it could be expected that Ruth may have had reduced production of digestive enzymes due to gut damage. The lipase in the donated breastmilk may have compensated for that. Breastmilk also provides amylase which may have helped digest the rice cereal and stewed apple Ruth was able to eat after a few days.
Breastmilk would not provide adequate levels of protein to maintain body weight in an adult unless unrealistic volumes were consumed, but towards the end of life for a cancer patient, maintaining normal protein nutrition becomes less important than maintaining hydration (Arends et al 2006).
Anti-inflammatory and anti-anorexic properties
In a person with cancer, pro-inflammatory cytokines and leptin concentrations increase, accompanied by metabolic changes, loss of appetite and weight loss (Arends et al 2006). Omega-3 polyunsaturated fatty acids have been studied for their potential as useful additions to oral nutrition in cancer patients because of their anti-inflammatory properties (Prevost & Grach 2012). Similarly, breastmilk's anti-inflammatory components might partly correct the pro-inflammatory status of a person with cancer. In breastmilk non-inflammatory and anti-inflammatory immune components (including soluble receptors for pro-inflammatory cytokines) predominate, which may perhaps modify the effects of the pro-inflammatory cytokines induced by immunologic challenge (Hawkes et al 1999; Le Bouder et al 2006; Brandtzaeg 2010).
It has been shown in infants that breastfeeding ameliorates the anorexia that can follow immunological challenge such as mild illness or vaccination (Lopez-Alarcon et al 2002). After a vaccination breastfed infants showed no decrease in milk intake, in contrast to artificially-fed infants. Artificially-fed infants are also more likely to develop fever after a vaccination than breastfed infants--an indication that breastmilk's anti-inflammatory properties function at the whole person level, at least in the presence of a mild stimulus (Pisacane et al 2010).
A person suffering from loss of appetite can readily be 'put off' by strong tastes and smells of food. Among a study of cancer patients taking pasteurised human milk some found the taste awful and had to mask it. Some took raw milk and described it as 'delicious, sweet and lively' (Rough et al 2009). Ruth was given unpasteurised milk. The taste was acceptable and drinking was probably easier than eating for her, since chemotherapy often decreases saliva production and makes swallowing solid food difficult.
Antioxidants in breastmilk
In cancer patients, signs of oxidative stress are raised and antioxidants are at low levels (Arends et al 2006). Breastmilk provides a number of recognised antioxidants and breastfed infants show evidence of more effective antioxidant systems than artificially-fed infants (Friel et al 2002; Shoji et al 2004). Breastmilk's antioxidant systems might be useful to a person with cancer. The pathogenesis of cancer-related anorexia/ cachexia syndrome (CACS) is not yet fully understood, but it seems to be multifactorial and involve both inflammatory and oxidative stress (Laviano et al 2007). The weight loss and muscle loss that accompanies CACS is not resolved by simply increasing nutrient supply (Mantovani et al 2010). A trial of agents described as 'mildly effective' when given singly was recently found to be effective at relieving cancer-related anorexia/ cachexia syndrome when given in combination. The researchers proposed the combination in the expectation that the multifactorial CACS would be better addressed by multiple treatments (Mantovani et al 2010). Accordingly while breastmilk's supply of digestible nutrition was likely to be important to Ruth's improvement, it is not enough to completely explain it. Breastmilk's mix of anti-inflammatory and antioxidant components may have been effective in alleviating Ruth's anorexia.
Anticancer components in breastmilk
Reports of components in breastmilk that have the capacity to kill cancer cells in vitro have given some patients the hope that breastmilk might help them. Rough and others (2009) reported a study of 10 cancer patients' experiences using human milk. Most of the patients reported feeling some benefit, such as an increase in appetite or less nausea during chemotherapy. However, the study did not use any objective measure of improvement in the patients' health.
Human Alpha-lactalbumin Made LEthal to Tumour cells (HAMLET) is a protein-fatty acid complex derived from human milk, which kills cancer cells Synthetic HAMLET has been shown to reduce papillomas and bladder cancer when applied directly HAMLET is formed in the laboratory at low pH from [alpha]-lactalbumin and oleic acid which are both present in human milk, though the HAMLET complex is not. Researchers have speculated that HAMLET may form in the infant's stomach and this might contribute to the difference in incidence of cancer between breastfed and artificially-fed infants (Mok et al 2007). (Breastfed infants have a lower incidence of acute myelogenous leukaemia and acute lymphocytic leukaemia than artificially-fed infants [Ip et al 2007]).
TNF-Related Apoptosis-Inducing Ligand (TRAIL) is another component of human milk that is able to kill cancer cells. TRAIL binds to 'death receptors' on the surface of cancer cells and sets off the process of cell death or apoptosis. It is not entirely clear why TRAIL doesn't kill normal cells, but possibly normal cells have many decoy receptors that compete with the active death receptors for binding to TRAIL. TRAIL has other functions too and may be involved in promoting cell differentiation in the gut lining Researchers are investigating ways to use TRAIL in cancer treatments (Stolfi, Pallone & Montelone 2012; Allen & El-Deiry 2012). TRAIL has been found in human milk at levels 100 times those in serum (Davanzo et al 2012).
However, Ruth's cancer was advanced by the time she was given breastmilk and it could not be expected that the anticancer activities in breastmilk would have had much impact on the tumour.
Immune components in breastmilk
It is well known that breastfed infants have lower rates of infection than artificially-fed infants. Breastmilk contains numerous immunologically active components. Antibodies are probably the best known immune component of breastmilk. Lactoferrin has antibacterial and antiviral properties, lysozyme has antibacterial functions, partially digested [alpha]-lactalbumin fragments have prebiotic functions and bactericidal functions (Lonnerdal 2010). Oligosaccharides are found in human milk in a greater variety than in other milks and at high concentrations--up to 15g/L (Kuntz, Rudloff & Kunz 2008). Oligosaccharides act as decoys to some pathogens: they bind specific microbes in the gut and in that way prevent the microbes from binding to and penetrating the gut wall. Oligosaccharides are also prebiotics, providing nutrition to particular probiotic bifidobacteria and so helping establish a healthy gut flora (Bode 2 009). The lactating breast can be considered a part of the mucosal immune system and produces antimicrobial peptides that are secreted into breastmilk (Murakami et al 2005). The immune components in breastmilk support the infant's developing immune system Chemotherapy increases the cancer patient's risk of infection by damaging the patient's immune system and the immune system of breastmilk could be expected to ameliorate that effect.
The use of breastmilk in adults
Donated milk has been provided to sick children and adults with apparent benefit. Arnold has reported several instances when human milk was the only food tolerated by sick infants, children or adults and other instances where it appeared to influence improvement in colitis or gastro-oesophageal reflux in an adult (Arnold 1996; Arnold 1995a +b; Wiggins & Arnold 1998).
Human milk was used to provide a source of IgA for two IgA-deficient liver transplant recipients. Their infection-free recovery period was significant because liver transplant in IgA-deficient individuals is associated with high rates of mortality, largely due to post-surgical infections (Merhav et al 1995).
Human milk is an easily digested, antioxidant, anti-inflammatory, anti-infectious food. The same factors that make it suitable for the immature gut of the human infant may be useful to an adult with a damaged or inflamed gut. It is unlikely that breastmilk will ever be available in such quantities that it could serve as a complementary medicine, but for those who want to use it and have donors willing to provide some, it may be a useful adjunct to conventional medical treatment.
Ruth's story is as much about human generosity as it is about human milk. Ruth's last weeks were warmed by the gift she was given and, in reflecting on that gift, I am reminded that in every case breastfeeding is more than providing nutrition. Donation makes the 'gift' aspect of breastmilk obvious and a mother breastfeeding her own child is also giving more than food. Even while considering the physiology of human milk it is good to remember that giving human milk is fundamentally about human relationships.
'Ruth goes home' was written by Helen Gardner and first published by Hybrid Publishers in Snapshots from our lives Reproduced with permission.
Extract from the Australian Breastfeeding Association's Human Donor Milk Policy
* The Association does not facilitate informal milk sharing by linking private donors and recipients.
* The Association accepts no responsibility for expressed breastmilk donated by its members ABA members who donate expressed breastmilk do so as breastfeeding mothers, and not on behalf of the Association.
* The Australian Breastfeeding Association may provide information about donor milk resources, including links on the Association website, to human milk banks and other resources as a service to the community and to assist parents to make an informed decision. The Association does not necessarily endorse the information available from these resources and makes no representations as to their accuracy.
Keywords: cancer, donor breastmilk, adult use of breastmilk, antioxidant, antiinflammatory
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* B'nai B'rith: A Jewish organisation promoting benevolence, fellowship and harmony.
** Hatzolah: A Jewish, volunteer, first aid organisation.
*** Mitzvah: A moral deed or act of human kindness.
Elizabeth McGuire BSc IBCLC
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