HCA Lactation Consultant Workgroup
Final Draft
5-12-10/8-31-10
PURPOSE: To provide clinical guidelines for the use of pasteurized banked donor milk.
BACKGROUND: Human milk is the standard food for infants and young children including premature and
sick newborns with rare exceptions. Human milk provides optimal nutrition, promotes normal growth and
development, and reduces the risk of illness and disease. The unique composition of human milk includes
nutrients, enzymes, growth factors, hormones, and immunological and anti-inflammatory properties that
have not been duplicated. Exclusive breastfeeding for six months is recommended with introduction of
complementary nutritionally adequate foods at about this time. In situations where mothers’ own milk is
not available, provision of pasteurized, screened donor milk is the next best option particularly for ill or
high-risk infants.
DEFINITION:
Pasteurized Donor Milk: milk that has been processed per Human Milk Banking Association of North
America (HMBANA) guidelines.
POLICY:
Parent/legal representative of every infant will be informed of the availability of donor milk as an option
when supplementation is medically indicated and mother’s own milk is not available in adequate volumes.
STORAGE:
Refer to Collection, Storage and Handling of Human Milk for the Hospitalized Infant.
PROCEDURE:
PROCEDURE
Notify parents(s)/legal representative of recipient infant of the need for and use of
pasteurized banked donor milk with an opportunity to ask questions and accept or
refuse the use of donor milk.
Obtain order to use donor milk.
Obtain parent(s)/legal representative Donor Milk Consent Form.
Verify signed original consent in recipient infant’s medical record prior to use.
Store and handle donor breastmilk per HCA Perinatal Clinical Services Group
Guidelines for the Collection, Storage and Handling of Human Milk for the
Hospitalized Infant.
RESPONSIBILITY
MD/NP/RN/IBCLC
MD/NP/RN/IBCLC
MD/NP
RN/IBCLC
RN/IBCLC
A. Remove frozen donor milk from freezer and label with recipient infant’s electronic medication label or
identification label including infant’s name and medical record number. Record date and time milk is
removed from the freezer along with staff initials on the label.
B. Document lot number and expiration date of donor milk on infant’s record.
REFERENCES:
CPQCC Nutrition Toolkit Appendices, 2008. Appendix 1-E1: Example of Nutrition Dashboard; Appendix
1-F: VON: Potentially Better Nutritional Practices; Appendix 4-C: Nutritional Support of the VLBW Infant;
Appendix 4-D: Nutritional Support of the VLBW Infant. www.cpqcc.org
CPQCC Nutrition Toolkit Appendices, 2008, Attachment A (Heat Processed, Banked Donor Breastmilk
Information Sheet) and Attachment A1 (Fresh Donor Breastmilk Information Sheet for Recipient Parent)
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HCA Lactation Consultant Workgroup
Final Draft
5-12-10/8-31-10
Vaucher,Y, Wight,N. CPQCC Care and Management of the Late Preterm Infant Toolkit: Nutrition (2007),
pp 1-7. www.cpqcc.org
AAP Policy Statement http://aappolicy.aappublications.org/cgi/reprint/pediatrics;115/2/496.pdf
Renfrew MJ, Craig D, et al. “Breastfeeding promotion for infants in neonatal units: a systematic review
and economic analysis.” Health Technology Assessment NIHR HTA programme, www.hta.ac.uk, August,
2009; Vol 13: No. 40.
CDC Maternity Care practices, CDC Guide to Breastfeeding Interventions: Maternity Care Practices.
http://www.cdc.gov/breastfeeding/pdf/BF_guide_1.pdf
CDC National Survey of Maternity Practices in Infant Nutrition and Care (mPINC), 2007.
http://www.cdc.gov/breastfeeding/pdf/Maternity_Care_Practices.pdf
Protecting, Promoting and Supporting Breastfeeding: The Special Role of Maternity Services, a joint
WHO/UNICEF statement published by the World Health Organization.
http://www.unicef.org/newsline/tenstps.htm
HMBANA: The Value of Human Milk, Position Paper on Donor Milk Banking.
http://www.hmbana.org/downloads/position-paper-donor-milk.pdf
Jones F, “History of North American Donor Milk Banking: One Hundred Years of Progress.” J Hum Lact
19 (3), 2003
Arnold Lois D.W., “Milk Banks and Milk Banking: Clinical Uses of Donor Milk” J Hum lact 6(3), 1990
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