Obtaining_and_Using_Donor_Milk_in_the_NICU

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Karen Strube RNC-OB, IBCLC
Lactation Program Coordinator
Wheaton Franciscan Healthcare All Saints
Objectives – Following this presentation
you will be able to:
Describe the benefits of using donor milk
for preterm or ill infants.
 Identify the infant who would benefit from
the use of donor milk.
 Discuss with parents how donor milk is
used in the NICU and the process for
becoming a donor.
 Describe the process for obtaining donor
milk from a HMBANA milk bank.
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Mother’s own milk is preferred for
infants in the NICU
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Every mother should be informed about the importance of
her own milk for her infant – this information should be
provided; prenatally, antepartum, or post partum – we don’t
“badger mothers” or “talk them into it” – we provide
accurate information, document and communicate the
mother’s wishes.
For the critically ill/small infant we are not asking the mother
to “breastfeed”. After providing the appropriate information
use the phrase “your milk is important medicine for your
baby – would you consider providing pumped milk for your
baby?”
If the mother is unable or does not desire to provide her own
milk the MD will discuss and obtain the consent for use of
donor milk.
Why Donor Milk?
Reduce NEC, Sepsis, Length of Stay
 Decrease Mortality
 Lead the way! Only a handful of Wisconsin
hospitals currently use PDHM.
 Increase patient satisfaction
 Reduce healthcare costs and improve long
term outcomes
 Increase RN/MD satisfaction by decreasing
cases of fulminant/surgical NEC

Recommendations
“Growing evidence supports the role of donated
human milk in assisting infants with special needs,
such as infants in newborn intensive care units who
are unable to receive their own mothers’ milk, to
achieve the best possible health outcome.”
US Surgeon General (2010)
“Where it is not possible to breastfeed, the first
alternative, if available, should be the use of human
milk from other sources. Human milk banks should
be made available in appropriate situations.”
WHO/UNICEF (1980)
Recommendations Continued
“Banked pasteurized donor human milk has been
found to be safe and nutritionally sound for babies
who do not have access to their own mothers’ milk”
American Academy of Family Physicians (2008)
“Banked
human milk may be a suitable feeding
alternative for infants whose mothers are unable or
unwilling to provide their own milk. Human milk
banks in North America adhere to national guidelines
for quality control of screening and testing of donors
and pasteurize all milk before distribution.”
American Academy of Pediatrics (2005)
Recommendations Con’t.
“ABM Accepts and Endorses (the) Human Milk Banking Association of
North American, Position Paper on Donor Milk Banking.”
Academy of Breastfeeding Medicine Position on Breastfeeding (2008)
“The value of human milk in reducing the incidence of NEC has
influenced the growing use of pasteurized donor human milk for infants at
high risk for NEC. When mother’s milk is not available, providing
pasteurized donor m ilk from appropriately screened donors from an
approved milk bank offers immunoprotection and bioactive factors not
found in infant formula and is the next best option particularly for ill or
preterm infants. Only human milk from facilities that screen and approve
donors and pasteurize d the milk should be used because there is risk of
disease transmission to the recipient from donors who are not screened
and from the use of unpasteurized milk.”
American Dietetic Association. Promoting and Supporting Breastfeeding. J
Am Diet Assoc. 2009; 109:1926-1942
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In 1985, the Human Milk Banking Association of
North America (HMBANA) was established to
provide evidence-based guidelines and standards
for the industry.
HMBANA milk banks are non-profit.
There are currently 14 milk banks in operation or
being developed in the United States.
Until the WI/IL milk bank is operational we order
from The Milk Bank of Indiana.
HMBANA Locations
Operating Milk Bank
Developing Milk Bank
Developing Local Milk Bank
The Mother’s Milk Bank of the Western Great
Lakes is a developing HMBANA milk bank.
This bank will serve Illinois and Wisconsin.
 The milk bank will increase awareness,
leading to increased utilization of PDHM.
 Milk donations from Illinois and Wisconsin
mothers will be used for local at-risk infants.

All Saint’s Milk Depot
We have been shipping milk since April.
 Qualified donors are able to drop off milk to
the lactation office for shipping to the milk
bank.

Milk Donor Screening Process
To become a milk donor, follow the below steps to
complete the simple screening process.
1. Learn how to donate through the Indiana Mothers’ Milk Bank
(IMMB) or call them at 317-536-1670 or toll free at 877-8297470.
2. The IMMB will explain its qualifications for milk donation.
After you complete their screening process, they will instruct
you to contact us by phone at 847.444.9256 or e-mail
[email protected]
3. The IMMB will arrange for your blood testing, at no cost to
you.
The screening process takes approximately 2-3 weeks to
complete.
When you are approved as a donor, please make
arrangements to drop off your milk at the closest milk depot in
Illinois or in Wisconsin.
Feel free to contact our Executive Director by phone at
847.444.9256 or e-mail [email protected]
Donors
Are healthy lactating women.
 Are mothers with an abundant milk
supply or grieving mothers who
donate their baby’s stored breast milk.
 Must consent to blood tests for : HIV, Hep B, Hep
C, Syphilis, and HTLV.
 Must obtain medical clearance from physician.
 Must complete lifestyle and health questionnaires
(similar to blood donors).
 Can only take a few approved medications determined by the milk bank
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Requirements for Donation
It is important to follow the milk collection and storage procedures
described by the IMMB. We request that you plan to donate a minimum
of 100 ounces over the course of your time as a milk donor. Exceptions
to this minimum are made for bereaved mothers. We can accept milk
you stored before contacting us as long as:
1. You were not ill and/or taking any non-approved medications.
2. Your frozen milk has been in a refrigerator-freezer for less than 3
months or in a stand-alone deep freeze for less than 4 months.
3. Your milk is stored in clean, food-grade containers.
After your first donation, you may donate your milk in any amount until
your baby reaches 2 years of age. Milk storage containers are
available at many of our milk depots when you drop off milk.
Bereavement Donation
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Stored breast milk represents the mother’s love
love and devotion to her baby.
The milk symbolizes the baby.
Mothers “cannot bear to throw away the milk.”
Milk donation allows these moms to continue to
mother and nurture by helping other babies in need.
This donation honors and memorializes their baby.
There is NO minimum donation.
Mothers who do not qualify due to medications/or
history can still donate milk for research.
Our lactation staff can help support these mothers
through the donation process.
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Letter to Mother
Please accept our deepest sympathy for the loss of your baby. We respect hat
this is a sad time for you and your family. As a mother who pumped milk for her infant,
we appreciate the dedication and love you put into pumping your milk. You may have
unused milk that is stored in a freezer at the hospital or at home.
Some mothers take comfort in donating their stored milk to a milk bank. Milk
banks can process the milk and send it to neonatal intensive care units where it can be
used by premature or sick babies. The NICU at Wheaton Franciscan Healthcare – All
Saints has partnered with The Milk Bank of Indiana to help mothers who would like to
donate their stored breast milk. If you would like to donate your stored breast milk, we
can help you with what is needed to send the milk to the Indiana Milk Bank. In honor of
your donation, The Milk Bank of Indiana will have your baby’s name engraved on a leaf
on their “Giving Tree” memorial.
We respect that you may need time to think about donating your stored milk,
know that you can contact us at any time to talk about milk donation or any breast
concerns, and return of the rented breast pump. We will keep your stored milk safe at
the hospital for up to four weeks. During this time you can choose to donate, pick up,
or have us discard it. We will support and honor any decision you make regarding your
stored milk.
Our thoughts are with you.
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Sincerely,
Milk Processing
Scrubbing
Pooling
Milk Processing
Pouring
Pasteurizing
Milk Processing
Labeling
Microbial Testing
Holder Pasteurization
Milk is pasteurized in a shaking water bath or
automatic pasteurizer for 30 minutes at 62.5°
Celsius.
 This method of pasteurization destroys HIV
and CMV*.
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* www.latrobe.edu/au/microbiology/table7.html
Bacteriologic Testing
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After pasteurization, one bottle from each batch
is sent for culture. If there is any growth, or
contamination, the entire batch is discarded.
NEC: Feeding Issues
Infants fed PDHM experienced fewer
episodes of feeding intolerance and
diarrhea.1
 Infants fed high proportions of human
milk achieved 100 ml/kl/d enteral
feedings 4.5 days faster, and 150 ml/kl/d
5 days faster than the low
human milk group.2
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1. Boyd et al., 2007
2. Sisk et al., 2008
Other outcomes associated with
human milk feedings for
premature infants:
 Reduced
incidence of sepsis
 Shorter length of stay
 Decreased incidence of ROP
 Improved developmental outcomes
Ronnestad et al., 2005
Indications for PDHM
Birth weight equal to or less
than 1500 grams
 GI diagnosis (short-gut syndrome,
hirschsprungs, malabsorption, GI
surgery)
 NEC or a history of NEC
 Renal failure
 Feeding intolerance
 Some inborn errors of metabolism
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So how did we get the
process going? (refer to handouts)
Progression to use of PDHM
 Guideline for the use and storage of
pasteurized donor human milk (PDHM)
in the NICU
 Consent for use of PDHM
 Loss Letter

Ordering Donor Milk
Pasteurized donor human milk is dispensed by prescription only. The
highest-priority recipients are premature and ill hospitalized infants. All
infants who have a medical need for human milk can obtain donor
human milk by prescription.
Until the processing and distribution facility of the Mothers’ Milk Bank of
the Western Great Lakes is operational, pasteurized donor human milk
can be ordered from our Mentor Bank in Indiana.
Indiana Mothers’ Milk Bank
4755 Kingsway Drive, Suite 120
Indianapolis, IN 46205
Phone (317) 536-1670
Toll-free 1 (877) 829-7470
FAX (317) 536-1676
Contact:
Janice O’Rourke, Executive Director
[email protected]
Guidelines For Use of PDHM
Need Physician Order
 Need parental consent prior to use
 Will start MEF’s on day one of life
 Premature infants will receive Preterm
PDHM/Term milk for 4 weeks. (Preterm milk is
rarely available)
 All infants will transition to “Term” milk after 4
weeks of life, or if they are >34 weeks.
 Infants will wean after 4 weeks, when they attain
1500 grams.
 Infants will not go home on PDHM, they will be
weaned to formula.
 Infants may receive additional PDHM if they
experience feeding intolerance
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The Process
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The lactation office will assess the stock of PDHM
daily/weekly and keep a minimum of (10) 4oz bottles kept on
hand.
PDHM will be ordered by the materials management
coordinator, shipped by FedEx and will not be delivered on
Saturday or Sunday.
Shipments will be received at the NICU front desk – if the LC
(lactation consultant) is working, she will be paged to
assume responsibility for the milk, if unavailable the charge
nurse will sign for the milk. Only if the charge nurse and LC
are unavailable is the unit clerk to sign for the milk.
The person signing for the milk will check the milk against
the invoice, assess the condition of the milk and transfer the
milk to the freezer in the nutrition room.
Process Con’t.
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If the shipment does not match the invoice, or if
there is a problem with the shipment (broken
bottles or thawed milk), the person receiving the
milk will contact The Milk Bank of Inidiana
immediately.
The milk will be logged into the Donor Milk
Receiving Form in the PDHM Log Book kept in the
Nutrition Room
PDHM will be stored in accordance with the
current HMBANA guidelines – in the NICU freezer
for 6 months (all milk is stickered with an
expiration date).
PDHM must be used within 24 hours of thawing.
Preparation and Feeding
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A single “Unit Bottle” of PDHM can be used for several infants. The
bottle will be labeled with the date/time of initial thaw. Several bottles
or syringes can be prepared from the “Unit Bottle”. Please draw up
only what is needed so there is no wasting of PDHM.
The unit bottle will be thawed in accordance with our breast milk policy.
The bottle will be thawed to cold, not room temperature.
The unit bottle will be labeled with a “Date/Time Thaw” label. This label
will contain the date and time of initial thaw. The original label from the
milk bank will NOT be removed.
The unit bottle will be stored in a designated PDHM refrigerator in the
NICU Nutrition Room.
The RN will pour the desired amount of PDHM into a volufeed. She/he
will recap the unit bottle and return it to the PDHM refrigerator. She/he
will draw up feedings into syringes or distribute the PDHM into bottles
in the infant’s pod. Syringes will not enter the unit bottle. The RN will
pour the desired amount of PDHM into a volufeed first, and then draw
up MEF’s from the volufeed (not from the unit bottle).
Preparation and Feeding Con’t.
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You may prepare one or several feedings for the same
infant (up to the expiration time of the milk).
Label each syringe/bottle with the infant’s sticker and
identify the milk as PDHM.
PDHM can be fortified as per current NICU protocol.
Enter the infant’s name and milk lot# on the PDHM log,
which will be kept in the PDHM Log Book in the NICU
Nutrition Room.
Chart the feeding as “Donor Human Milk” and include
the donor milk# in the EHR.
All Forms/Logs must be retained 20 years! When
forms are complete - give to the NICU Manager
PDHM Log Book
Pasteurized Donor Human Milk (PDHM)
Log
Book
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Wheaton Franciscan Healthcare – All
Saints
St. Luke’s Health Pavilion NICU
(stored in Nutrition Room)
Log Book Contents
Guidelines for the use and storage of
pasteurized donor human milk in the
NICU
 Information/Consent for Heat Processed
Banks Donor Human Milk
 Donor Human Milk Receiving Form/Log
 Donor Milk Usage Form/Log
 Donor Human Milk Recall Form/Log
 Date/Time Thaw Labels

Donor Human Milk Receiving
Form/Log
Donor Milk Usage Form/Log
Donor Human Milk Recall
Form/Log
Challenges Along the Way
What’s next…………
Introduction of the Milk Tech Role
 Using donor milk for hypoglycemic infants.
 Using donor milk in any breastfeeding infant
who us unable to breastfeed until mother’s
milk supply is established.
 Establishing the ability of donor mothers to
drop off milk donations at any Wheaton
facility to be transported to All Saint’s Depot
and shipped to the Milk Bank
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A powerful statement…
“Substantial clinical evidence has placed
human milk feeding and donor human
milk as a basic right for preterm
infants…Banked donor milk should be
promoted as a standard component
of health care for premature infants.”
Arslanoglu, Ziegler, & Moro., 2010
References
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Arslanoglu,S., Ziegler.E. E., Moro, G. E. (20210). Donor human milk in preterm infant
feeding: Evidence and recommendations. Journal of Perinatal Medicine, 38(4), 347351.
Advocate Medical Group Section of Neonatology (2010). Guideline for the use and
storage of pasteurized donor human milk in the NICU.
Arnold, L.W. (2002). The cost effectiveness of using banked donor milk in the neonatal
intensive care unit: Prevention of necrotizing enterocolitis, J Human Lact, 18(2), 172177.
Boyd, C.A., Quigley, M.A., & Brockelhurst, P. (2007). Donor breast milk versus infant
formula for preterm infants: Systematic review and meta-analysis. Ach Dis Child Fetal
Neonatal Ed, 92, F169-F175. doi: 10.1136/adc.2005.089490.
California Perinatal Quality Care Collaborative (2008). Quality Improvement Toolkit:
Nutritional Support of the Very Low Birth Weight Infant.
Edwards TM, Spatz DL (2012). Making the case for using donor human milk in
vulnerable infants. Advances in Neonatal Care (2012) 12(5), 273-278.
Ewaschuk JB, Unger S, Harvey S, O’Connor DL, Field CJ. (2011). Effect of
pasteurization on immune components of milk: implications for feeding preterm infants.
Appl Physiol Nutr Metab. 2011 Apr;36(2):175-82. Department of Agricultural, Food, And
Nutritional Sciences, University of Alberta, 4126 HRIF East, Edmonton, AB T6G2E1,
Canada.
Human Milk banking Association of North America, Inc. (2011). Best Practice for
Expressing, Storing and Handling Human Milk in Hospitals, Homes and Child Care
Settings. 3rd Edition.
References Continued
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McGuire, W., & Anthony, M.Y. (2003). Donor human milk versus formula for preventing
necrotizing enterocolitis in preterm infants: Systematic review. Arch Dis Child Fetal
Neonatal Ed, 88, F11-F14.
Meinzen-Derr, J., Poindexter, B., Wrage, L., Morrow, A. L., Stoll, B., & Donovan, E. F.
(2009). Role of human milk in extremely low birth weight infants’ rick of necrotizing
enterocolitis or death. Journal of Perinatology, 29, 57-62.
Miracle Dj, Szucs KA, Torke AM, Heft PR. (2011). Contemporary ethical issues in
human milk-banking in the United States. Pediatrics, (2011);128;1186-1191.
Ronnestad, A., Abrahamsen, T.G., Medbo, S., Hallvard, R., Lossius, K., Kaarensen, P.
I., Markstad, T. (2005). Late-onset septicemia in a Norwegian national cohort of
extremely premature infants receiving very early full human milk feedings. Pediatrics,
115(3), e269-e276. doi:10.1542/peds.2004-1833.
Sisk, P.M., Lovelady, C.A., Dillard, R.G., Gruber, K.J., & O’Shea, T.M. (2007). Early
human milk feeding is associated with a lower risk of necrotizing enterocolitis in very
low birth weight infants. Journal of Perinatology, 27, 428-433.
Sisk, P.M., Lovelady, C.A., Gruber, K.J., Dillard, R.G., & O’Shea, T.M. (2008). Human
milk consumption and full enteral feeding among infants who weigh less than or equal
to 1250 grams. Pediatrics, 121(6), e1528-e1533. doi:10.1542/peds.2007-2010.
Underwood MA. (2013). Human milk for the premature. Pediatr Clin N Am 60 (2013)
189-207.
Wright, N.E., Morton, J.A., & Kim, J.H. (2008). Best Medicine: Human Milk in the
NICU.
Thank You
Summer Kelly, RN, BSN, IBCLC
(Mothers’ Milk Bank WGL) for content,
slides and support during this process.
Mothers Milk Bank of Western Great
Lakes
Wisconsin Association of Lactation
Consultants
The Milk Bank of Indiana
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