Breastmilk - Safe Management

7/28/2019 Breastmilk - Safe Management

1/9

Breastmilk: Safe Management 1 WACS Clinproc7.3May-11

P2010/0300-001WACS CLINProc7.3

Title: Breastmilk: Safe Management

Replaces: Breastmilk and Expressed Breastmilk (EBM): Part A & B 3.6Description: Handling, labelling and dispensing of EBM

Target Audience: Midwives and registered nursesKey Words: Expressed breastmilk, handling, labelling, dispensing, checking

Policy Supported: P2010/0299-003 Breastfeeding Protocol

Compliance with this policy is mandatory.

1. Rationale

1.1 Womens & Childrens Services are required to safely manage and store expressedbreastmilk (EBM) as babies must only be fed breastmilk from their biologicalmother.

1.2 The importance of babies receiving breastmilk is well documented in the literatureand supported by the NHMRC Infant Feeding Guidelines for Health Workers (2003).Mothers may need to express their breastmilk for a variety of reasons, such as iftheir infant is sick or premature, if the milk supply needs to be increased or if motherand baby are temporarily separated.

1.3 Breastmilk is a body fluid which has the potential for the possible transmission ofinfectious pathogens if contaminated and/or given to the wrong infant. Risk oftransmission of disease by this route is low but not zero.

1.4 Standard precautions are to be applied during collection, storage, handling andadministration of EBM. Intact skin (or skin integrity) may be confirmed by use ofalcoholic gel rub prior to procedure.

1.5 It is important to note that there is the potential for babies to receive incorrect breastmilk in any clinical area where mothers and babies are separated and/or expressedbreastmilk (EBM) is dispensed. Factors that may lead to babies receiving theincorrect breastmilk include: separation of mothers and babies, inadequateidentification processes, and the absence of systems to manage safe storage anddispensing of EBM.

1.6 If an infant is exposed or suspected of being exposed to non-maternal milk, theinfant is to be classified as having potential exposure to Blood Borne Viruses, referto Section 4. Management of Incidents Where Babies Receive the IncorrectBreastmilk of this policy for actions.

2. Strategies to Reduce the Risk of Babies Receiving Incorrect Breastmilk
http://pssbpr-trim02/PandP/showdoc.aspx?recnum=P2010/0299-003http://pssbpr-trim02/PandP/showdoc.aspx?recnum=P2010/0299-003http://pssbpr-trim02/PandP/showdoc.aspx?recnum=P2010/0299-003


2/9


Unless clinically indicated, babies should room in with their mothers. All clinicalareas that manage EBM or where breast-fed babies are potentially separated fromtheir mothers should implement the following strategies:

2.1 Where babies are separated from their mothers

Babies should not be separated from their mothers for any length of timeunless clinically indicated

On return to their mother, identification of both mother and baby should bechecked prior to breastfeeding

When babies and mothers are separated, for example, when babies are in-patients in the Special Care Nursery (Ward 4N), correct identification ofthese babies should occur at all times, by checking infant identification tag.

2.2 Identification of babies

Ensure all babies have secure identification in place on two sites at all times

eg. leg and arm Two people (parent and staff member or two staff) check the name of baby

using the identification tags on the baby before feeding with EBM (see 2.5below), or before giving the baby to the mother to feed when mother andbaby have been separated

Be aware of babies with similar or the same names. Place alert label on EBMRegister page

Communicate to parents the importance of ensuring that their baby hascorrect identification tags at all times

Identification tags are to be replaced immediately if removed.

2.3 Storage fridge/freezer environment

Breast Milk Roomtemperature (26C or lower)

Refrigerator(4 C or lower)

Frozen

Freshly expressed intoclosed container

6-8 hrsIt is preferable to storemilk in fridge ifavailable.

3-5 days (4C or lower)store in the back offridge where it iscoldest

2 weeks in freezercompartment inside fridge.3 months in freezer sectionof refrigerator with separate

door6-12 months in deep freezer(-18 C or lower)

Previously frozen-thawed in refrigeratorbut not warmed.

4 hours or less (ie: thenext feeding)

24 hours Do not refreeze

Thawed outsiderefrigerator in warmwater

For completion offeeding

4 hours or until nextfeeding

Do not refreeze

Infant has begunfeeding.

Only for completion offeeding then discard.

Discard. Discard.

Source: Infant Feeding Guidelines for Health Workers (2003) NHMRC


3/9


When storing EBM, avoid overcrowding. Appropriately sized fridges/freezersshould be available

Patients with fridges in single rooms may use that fridge for EBM storage. EBMcontainers require appropriate labelling; however do not need to be entered intoEBM Register, unless EBM transferred to the 4O or 4N fridge or freezer.

To protect re-usable bottles, masking tape will be placed on same prior to EBMlabel.

Each baby should have a labelled storage basket/container for their EBM in thefridge/freezer.

Note the date and time of removal of frozen milk from freezer and placementinto fridge, on the 3rd and 4th column of the EBM Register page (Refer toAttachment One (1) Stock Code number 138509) and sign.

The stand-alone freezer in 4N has its own specific EBM Register to contain

page/s that list frozen milk contained within. Frozen EBM transferred fromfreezer to fridge should have details transferred to the EBM Register pagesspecifically for that baby.

If EBM is to be transported (for example, from the mothers home), frozen EBMmust be maintained in a completely frozen state and refrigerated milk kept at 4degrees C by using appropriate equipment (such as an esky and freezer brick).It should be placed in the refrigerator (or in the freezer if it is still frozen)immediately on arrival, with individual containers or syringes requiring individualEBM labelling (see 2.4) and entry into EBM Register page/s.

2.4 Labelling and EBM Register

All EBM containers should be consistently, correctly and clearly labelledusing specific pink EBM labels (Supply code: 138933) (exemptions to thisrule are listed below) with the following information:

o Name: Surname, Baby of, (infant first name if known)o Infant medical record number (URN)o date / time expressedo date / time thawedo Additives: type, date/time added

Where antenatal breastmilk hand expression is indicated, a page ofcomputer formatted labels with name and infant URN OR a page of pink-coloured EBM labels should be given to the mother to take home. Labelsshould be affixed to the syringe with middle of label folded in half, so thenumbers on the syringe are visible (Refer to 2.3). (Refer also toBreastfeeding Protocol and patient pamphlet Antenatal Expressing &Storing of Colostrum.)

o If computer formatted labels are used, the mother is instructed to writethe date and time of expressing on the label

o If pink EBM labels are used, the infant URN number can be written forthe mother to refer to.


4/9


Premature or sick infants (4N) who are in-patient for an extended period oftime may be issued their own computer formatted labels.

EBM placed in the fridge or freezer should have labelling checked by twopeople (parent and staff member or two staff) and recorded in the EBMregister.

Policy regarding labelling applies equally to EBM expressed in the hospital,and to EBM brought from home to the hospital (refer to 2.3).

Fortified EBM should have labelling checked and EBM Register updated bytwo people as per protocol.

Combining of individual containers of EBM should also have labellingchecked and re-issued, with EBM Register updated as per protocol.

2.5 Checking of EBM prior to feeding a baby

The checking of EBM prior to feeding the baby will be carried out by two people(parent and staff member or two staff) and should be treated with the same

precautions as a blood product to ensure the following:

Correct EBM; check the details identified on the label are a match with thebabys records. If EBM dispensed from larger container, check both labels.

Correct feeding time and amount; check the EBM identification label with thebabys feed chart

Correct baby; check all of the above with the babys identification tags andsign in the EBM Register that this check is correct prior to the baby receivingEBM. To prevent over handling of any baby on frequent feed schedules(e.g., 1-2 hourly) in 4N, the URN is recorded on cot card and cross-checked

with infant name bands at beginning of each shift.

2.6 Dispensing of EBM

The dispensing of EBM needs to be treated with the same precautions as a bloodproduct with double checking. The two people can be a parent and staff member, ortwo staff members, who must ensure the following:

EBM that is dispensed into a second or third container/syringe should becorrectly labelled following checking with the original EBM container at timeof dispensing

Ensure that labelling is complete for each EBM container before dispensingfurther EBM

Do not thaw or warm breastmilk in the microwave due to the potential foroverheating and infant oral burns; also the potential to destroy some theproperties of the breastmilk.

2.7 At discharge:

Check fridge/freezer and EBM Register for EBM that needs to be sent home

with mother, and sign in EBM Register.

EBM Register pages are filed and stored in infant case notes/history.


5/9


2.8 Auditing and quality control

A member of staff should be allocated to check the fridge against theRegister daily to ensure each EBM container:

a) is appropriately labelled

b) is contained with others belonging to the same mother / infant within

a labelled basketc) is that of a mother and / or infant who is currently an in-patient and

has a page/s within the EBM Register or at the cot-side

d) Staff completing the check should sign the EBM Register pages toindicate that the check has been completed and is correct.

e) Refer also to Performance Indicators as written below.

3. Education/Communication

3.1 All staff managing breastmilk/EBM must comply with this guideline and

receive education at regular intervals by participating in inservice education.3.2 All policy changes relating to EBM will be communicated with staff through

appropriate inservice education and other means such as email,communication book.

3.3 All casual and pool/relieving staff are aware of current policy and practice inrelation to the safe management and storage of EBM as in 3.1 and 3.2

3.4 All parents are provided with appropriate information regarding the collection,labelling, storage and checking processes for the management and storageof EBM

3.5 Parents are made aware that the safest place for their baby in the postnatalward is next to their own bed.

4. Management of Incidents Where Babies Receive the Incorrect Breastmi lk

a) Referral to the Infection Control Nurse (page 505, extn 7669), OccupationalExposure Co-ordinator (7888) or After-Hours Nurse Manager is required, toprovide appropriate pre test and arrange post test counselling.

b) Notify Paediatrician on-call and when available, the Director of Paediatrics.

c) For confirmed exposure, document baby as exposed and milk donor assource.

d) If the exposure is a suspicion only and not able to be confirmed, writeunknown source.

e) Permission must be granted from exposed babys mother for testing ofinfants blood. Refer to point a).

f) The exposed babys mother is tested in case she is a blood borne viruscarrier should the baby return a positive Blood Borne Virus screen at a laterdate 10 ml sample to be obtained as per Occupational Exposure Protocol.

g) A sample ofminimum 1 ml of infant blood is needed to test for antibodies ofinfant. There may be a need for further blood requirements in the event thattesting needs to be extended.


6/9


h) The source (donor-milk mother), is asked to consent to blood testing as perOccupational Exposure Protocol.

i) If source unknown follow up screening needs to be attended at 12, 26 and52 weeks.

j) There is no evidence to support the use of invasive procedures to removethe milk from the babys stomach. Further, invasive procedures may causetrauma to the stomach and gastro-intestinal lining.

k) Note: Three (3) samples are sent to laboratory (i.e., source, exposed,exposeds' mother).

l) Documentation of incident in medical record.

m) Incident should be notified in Electronic Incident Monitoring System (EIMS).

Attachment 1 Expressed Breastmilk Label

Attachment 2 Expressed Breastmilk Register page

Attachment 3 References

Performance Indicators: Evaluation of compliance with guideline to be achievedthrough:o Medical record audit annually by clinical Quality

improvement Midwife WACS.o EBM Register pages checked daily by ward staff (see 2.4)o EBM Register will be audited randomly by WACS managers

and lactation consultants.

Review Date: Annually verified for currency or as changes occur, andreviewed every 3 years. September 2011

Stakeholders: Midwives and medical staff WACS

Developed by: Dr A Dennis Co-Director (Medical) Sue McBeath Co-Director

(Nursing & Midwifery) Womens & Childrens Services

Dr A Dennis Sue McBeathCo-Director (Medical) Co-Director (Nursing & Midwifery)Womens & Childrens Services Womens & Childrens Services

Date: _________________________


7/9


ATTACHMENT 1

EBM LABEL SAMPLE

Supply code: 138933

Required details:Babys and mothers names

Babys medical record numberAdditivesDate and time expressedDate and time thawed


8/9


ATTACHMENT 2: EXPRESSED BREASTMILK (EBM) REGISTER

Infant URN top half-label OR: Infant URN:____________________ DOB:_____/______/______

SURNAME:_________________FIRST NAME (IF KNOWN):_______________BABY OF:_____________________

D

ATE

T

IMEEBM

E

XPRESSED

P

LACEDIN

F

RIDGE

(

tickifapplic)

P

LACEDIN

F

REEZER

(

tickifapplic)

S

IGN

l

abelcorrect

S

IGN

l

abelcorrect

D

ATE/TIME

R

EMOVEDOUTOF

F

RIDGE

D

ATE/TIME

R

EMOVEDOUTOF

F

REEZER

S

IGN

Dispensing

/ M

other&baby

m

atch

S

IGNDispensing

/

M

other&baby

m

atch

DAILYCHECK:CORRECTLABELLING,EBM INBASKET,CURRENTIN-PATIENTIN EBM

REGISTER R

ANDOMAUDIT

W

ACSADMIN

Stock Code number 138509


9/9


ATTACHMENT 3

REFERENCES

Barry, C. & Lennox, K. (1998). Management of Expressed Breast Milk, Is the right breastmilk being fed to infants? Canadian J ournal of Infection Control. Spring, 16-19.

Dougherty, D. & Giles, V. (2000). From Breast to Baby: Quality assurance for breast milk

management. Neonatal Network. 19:7. 21-25.

Gilks J , Gould D, Price E (2007) Decontaminating breast pump collection kits for use on aNeonatal Unit. Review of current practice and the literature, in Journal of NeonatalNursing, 13: 191-198.

May J (2003) Tables of the antimicrobial factors and microbiological contaminants relevantto human milk banking,http://www.latrobe.edu/microbiology/

National Health and Medical Research Council (2003). Food for Health: Dietary Guidelinesfor Children and Adolescents in Australia Incorporating the Infant Feeding Guidelines for

Health Workers. Commonwealth. AGPS.

NSW Department of Health (2006). Breastfeeding in NSW: Promotion, Protection andSupport Policy Directive PD2006_012. Further details are available in the NSW DOHSafety Advocate (J uly 2004) (http://www.health.nsw.gov.au/pubs/s/pdf/safety_ad_7.pdf).PD2005_311 HIV, hepatitis B and hepatitis C - Management of Healthcare workerspotentially exposed provides direction on the management of potential exposure toinfectious pathogens.

NSW Department of Health (2003). Incident Management Policy PD 2006_030.

NSW Department of Health (2006) Breastmilk Safe Management PD2006_088. Online:http://www.health.nsw.gov.au/policies/pd/2006/PD2006_088.html

Pittard W, Geddes K, Brown S, Mintz S & Hulsey T (1991) Bacterial contamination ofhuman milk: container type and method of expression,Am J Perinatology, 8 (1): 25-27.

Robson A & Anderson K (1964) Thrush in infants: the disadvantages of teat sterilization bysodium hypochloride, Med J Aust, April: 519-521.

Tully M (2000) Recommendations for handling of mothers own milk, J Hum Lact, 16 (2) :149-151.

Warner, B. & Sapsford, A. (2004). Misappropriated Human Milk: Fantasy, fear and factregarding infectious risk. Newborn and Infant Nursing Reviews. 4:1. 56-61.

LGH Patient Information Pamphlet: Expressing & Storing Breastmilk in Hospital
http://www.latrobe.edu/microbiology/http://www.latrobe.edu/microbiology/http://www.latrobe.edu/microbiology/http://www.latrobe.edu/microbiology/

Documents

Breastmilk - Safe Management