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P2010/0300-001 WACS CLINProc7.

3 Title: Replaces: Description: Target Audience: Key Words: Policy Supported: Breastmilk: Safe Management Breastmilk and Expressed Breastmilk (EBM): Part A & B 3.6 Handling, labelling and dispensing of EBM Midwives and registered nurses Expressed breastmilk, handling, labelling, dispensing, checking P2010/0299-003 Breastfeeding Protocol

Compliance with this policy is mandatory. 1. 1.1 Rationale Womens & Childrens Services are required to safely manage and store expressed breastmilk (EBM) as babies must only be fed breastmilk from their biological mother. The importance of babies receiving breastmilk is well documented in the literature and 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 if their infant is sick or premature, if the milk supply needs to be increased or if mother and baby are temporarily separated. Breastmilk is a body fluid which has the potential for the possible transmission of infectious pathogens if contaminated and/or given to the wrong infant. Risk of transmission of disease by this route is low but not zero. Standard precautions are to be applied during collection, storage, handling and administration of EBM. Intact skin (or skin integrity) may be confirmed by use of alcoholic gel rub prior to procedure. It is important to note that there is the potential for babies to receive incorrect breast milk in any clinical area where mothers and babies are separated and/or expressed breastmilk (EBM) is dispensed. Factors that may lead to babies receiving the incorrect breastmilk include: separation of mothers and babies, inadequate identification processes, and the absence of systems to manage safe storage and dispensing of EBM. If an infant is exposed or suspected of being exposed to non-maternal milk, the infant is to be classified as having potential exposure to Blood Borne Viruses, refer to Section 4. Management of Incidents Where Babies Receive the Incorrect Breastmilk of this policy for actions. Strategies to Reduce the Risk of Babies Receiving Incorrect Breastmilk







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


Where babies are separated from their mothers Babies should not be separated from their mothers for any length of time unless clinically indicated On return to their mother, identification of both mother and baby should be checked prior to breastfeeding When babies and mothers are separated, for example, when babies are inpatients in the Special Care Nursery (Ward 4N), correct identification of these babies should occur at all times, by checking infant identification tag. 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 2.5 below), or before giving the baby to the mother to feed when mother and baby have been separated Be aware of babies with similar or the same names. Place alert label on EBM Register page Communicate to parents the importance of ensuring that their baby has correct identification tags at all times Identification tags are to be replaced immediately if removed.


2.3 Breast Milk

Storage fridge/freezer environment Room temperature (26 C or lower)

6-8 hrs It is preferable to store milk in fridge if available.

Refrigerator (4 C or lower)
3-5 days (4C or lower) store in the back of fridge where it is coldest


Freshly expressed into closed container

Previously frozenthawed in refrigerator but not warmed. Thawed outside refrigerator in warm water Infant has begun feeding.

4 hours or less (ie: the next feeding) For completion of feeding Only for completion of feeding then discard.

24 hours

2 weeks in freezer compartment inside fridge. 3 months in freezer section of refrigerator with separate door 6-12 months in deep freezer (-18 C or lower) Do not refreeze

4 hours or until next feeding Discard.

Do not refreeze


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

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When storing EBM, avoid overcrowding. Appropriately sized fridges/freezers should be available Patients with fridges in single rooms may use that fridge for EBM storage. EBM containers require appropriate labelling; however do not need to be entered into EBM 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 EBM label. Each baby should have a labelled storage basket/container for their EBM in the fridge/freezer. Note the date and time of removal of frozen milk from freezer and placement into fridge, on the 3rd and 4th column of the EBM Register page (Refer to Attachment 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 from freezer to fridge should have details transferred to the EBM Register pages specifically for that baby. If EBM is to be transported (for example, from the mothers home), frozen EBM must be maintained in a completely frozen state and refrigerated milk kept at 4 degrees 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 individual EBM labelling (see 2.4) and entry into EBM Register page/s.


Labelling and EBM Register All EBM containers should be consistently, correctly and clearly labelled using specific pink EBM labels (Supply code: 138933) (exemptions to this rule are listed below) with the following information: o o o o o Name: Surname, Baby of, (infant first name if known) Infant medical record number (URN) date / time expressed date / time thawed Additives: type, date/time added

Where antenatal breastmilk hand expression is indicated, a page of computer formatted labels with name and infant URN OR a page of pinkcoloured EBM labels should be given to the mother to take home. Labels should be affixed to the syringe with middle of label folded in half, so the numbers on the syringe are visible (Refer to 2.3). (Refer also to Breastfeeding Protocol and patient pamphlet Antenatal Expressing & Storing of Colostrum.) o If computer formatted labels are used, the mother is instructed to write the date and time of expressing on the label o If pink EBM labels are used, the infant URN number can be written for the mother to refer to.

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Premature or sick infants (4N) who are in-patient for an extended period of time may be issued their own computer formatted labels. EBM placed in the fridge or freezer should have labelling checked by two people (parent and staff member or two staff) and recorded in the EBM register. 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 by two people as per protocol. Combining of individual containers of EBM should also have labelling checked and re-issued, with EBM Register updated as per protocol.


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 the babys records. If EBM dispensed from larger container, check both labels. Correct feeding time and amount; check the EBM identification label with the babys feed chart Correct baby; check all of the above with the babys identification tags and sign in the EBM Register that this check is correct prior to the baby receiving EBM. 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.


Dispensing of EBM

The dispensing of EBM needs to be treated with the same precautions as a blood product with double checking. The two people can be a parent and staff member, or two staff members, who must ensure the following: EBM that is dispensed into a second or third container/syringe should be correctly labelled following checking with the original EBM container at time of dispensing Ensure that labelling is complete for each EBM container before dispensing further EBM Do not thaw or warm breastmilk in the microwave due to the potential for overheating and infant oral burns; also the potential to destroy some the properties of the breastmilk.


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.
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Auditing and quality control A member of staff should be allocated to check the fridge against the Register daily to ensure each EBM container: a) is appropriately labelled b) is contained with others belonging to the same mother / infant within a labelled basket c) 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 to indicate that the check has been completed and is correct. e) Refer also to Performance Indicators as written below.


Education/Communication 3.1 3.2 All staff managing breastmilk/EBM must comply with this guideline and receive education at regular intervals by participating in inservice education. All policy changes relating to EBM will be communicated with staff through appropriate inservice education and other means such as email, communication book. All casual and pool/relieving staff are aware of current policy and practice in relation to the safe management and storage of EBM as in 3.1 and 3.2 All parents are provided with appropriate information regarding the collection, labelling, storage and checking processes for the management and storage of EBM Parents are made aware that the safest place for their baby in the postnatal ward is next to their own bed.

3.3 3.4


4. Management of Incidents Where Babies Receive the Incorrect Breastmilk a) Referral to the Infection Control Nurse (page 505, extn 7669), Occupational Exposure Co-ordinator (7888) or After-Hours Nurse Manager is required, to provide 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 as source. d) If the exposure is a suspicion only and not able to be confirmed, write unknown source. e) Permission must be granted from exposed babys mother for testing of infants blood. Refer to point a). f) The exposed babys mother is tested in case she is a blood borne virus carrier should the baby return a positive Blood Borne Virus screen at a later date 10 ml sample to be obtained as per Occupational Exposure Protocol. g) A sample of minimum 1 ml of infant blood is needed to test for antibodies of infant. There may be a need for further blood requirements in the event that testing needs to be extended.
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h) The source (donor-milk mother), is asked to consent to blood testing as per Occupational Exposure Protocol. i) If source unknown follow up screening needs to be attended at 12, 26 and 52 weeks. j) There is no evidence to support the use of invasive procedures to remove the milk from the babys stomach. Further, invasive procedures may cause trauma 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 Attachment 2 Attachment 3

Expressed Breastmilk Label Expressed Breastmilk Register page References

Performance Indicators: Evaluation of compliance with guideline to be achieved through: 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, and reviewed every 3 years. September 2011 Midwives and medical staff WACS Dr A Dennis Co-Director (Medical) Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Stakeholders: Developed by:

Dr A Dennis Co-Director (Medical) Womens & Childrens Services

Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Date: _________________________

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ATTACHMENT 1 EBM LABEL SAMPLE Supply code: 138933 Required details: Babys and mothers names Babys medical record number Additives Date and time expressed Date and time thawed

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ATTACHMENT 2: EXPRESSED BREASTMILK (EBM) REGISTER Infant URN top half-label OR: Infant URN:____________________ DOB:_____/______/______

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

DATE / TIME REMOVED OUT OF FRIDGE DATE / TIME REMOVED OUT OF FREEZER SIGN Dispensing / Mother & baby match SIGN Dispensing / Mother & baby match

PLACED IN FRIDGE (tick if applic)

SIGN label correct

SIGN label correct

Stock Code number 138509

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PLACED IN FREEZER (tick if applic)



ATTACHMENT 3 REFERENCES Barry, C. & Lennox, K. (1998). Management of Expressed Breast Milk, Is the right breast milk being fed to infants? Canadian Journal 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 a Neonatal Unit. Review of current practice and the literature, in Journal of Neonatal Nursing, 13: 191-198. May J (2003) Tables of the antimicrobial factors and microbiological contaminants relevant to human milk banking, National Health and Medical Research Council (2003). Food for Health: Dietary Guidelines for 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 and Support Policy Directive PD2006_012. Further details are available in the NSW DOH Safety Advocate (July 2004) ( PD2005_311 HIV, hepatitis B and hepatitis C - Management of Healthcare workers potentially exposed provides direction on the management of potential exposure to infectious pathogens. NSW Department of Health (2003). Incident Management Policy PD 2006_030. NSW Department of Health (2006) Breastmilk Safe Management PD2006_088. Online: Pittard W, Geddes K, Brown S, Mintz S & Hulsey T (1991) Bacterial contamination of human 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 by sodium 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 fact regarding infectious risk. Newborn and Infant Nursing Reviews. 4:1. 56-61. LGH Patient Information Pamphlet: Expressing & Storing Breastmilk in Hospital

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