Policy and Procedure Recommendation for
Collection, Storage and Handling of Human Milk
for Hospitalized Infant
I. PURPOSE
To provide guidelines for the collection, storage and handling of human milk for the hospitalized
infant to optimize nutritional and immunological protection while minimizing the chance of
contamination or error.
II. RESPONSIBLE PERSON
Individuals designated by hospital with documented competencies
III. DEFINITIONS
Fresh Milk: freshly expressed milk that has not been refrigerated or frozen
Refrigerated Milk: milk stored at recommended refrigerator temperature and never frozen
Frozen Milk: milk stored at recommended freezer temperature
milk that has partially thawed but with ice crystals still present is defined as frozen
Thawed Milk: milk that has been previously frozen and no longer has ice crystals present
Pasteurized Donor Milk: milk that has been processed per HMBANA milk banking guidelines
Non-Pasteurized Donor Milk: milk from a mother other than the birth mother that has not been
processed per HMBANA milk banking guidelines. (Also known as fresh donated milk)
IV. POLICY STATEMENT
A. Good hand hygiene is of utmost importance to prevent contamination of human milk. OSHA
has determined that health care providers handling human milk are not required to wear
gloves. Human milk does not require biohazard labeling.
B. Use of non-pasteurized donor milk is not addressed in this policy.
C. Use of mother’s own milk for discharged infants follows different storage guidelines than those
expressed in this policy.
D. While most medications are compatible with breastfeeding, mothers should consult with the
infant’s health care provider and/or a registered lactation consultant concerning any medication
use while providing milk for their infant
HCA Lactation Consultant Workgroup
Final 7-28-10/8-31-10
E. Use milk (colostrum) in chronological order for the first two weeks. After that, use fresh milk
when available. If fresh milk is not available, use the oldest refrigerated and then the oldest frozen
milk.
F. Human milk will be stored as follows:
METHOD
HOSPITALIZED
INFANT’S OWN
MOTHER’S MILK
PASTEURIZED DONOR
MILK
Room Temperature:
~26C, ~79F
4 hours (best to refrigerate
immediately for
preterm/sick infant)
48 hours
4 hours
24 hours
24 hours
24 hours
48 hours
Not
recommended
3 months
Not
recommended
3 months
6 months
6 months
Refrigerated (never frozen):
1-4C, 35-40F
Insulated cooler with frozen gel
packs (see transporting/shipping
milk)
Completely thawed &
placed in refrigerator
Freezer Compartment (1
door refrigerator)
Freezer Compartment (2
door refrigerator) *not in door:
-18 to -22C, -8 to 0F
Deep Freezer:
-18 to -22C, -8 to 0F
n/a
G. All containers will be labeled with infant’s electronic medication label or infant’s identification
label with two unique patient identifiers. When milk is transferred to new container (syringes,
etc), the new label will contain original storage and handling information including lot number
of donor milk.
H. Date, type and amount of all additives to human milk will be documented on label.
I. Syringes and extension tubing for feedings will be changed every 4 hours.
IV. PROCEDURE
A. Collection
1. Provide instruction to mother and family of baby on pumping, storing and transporting
human milk for their hospitalized infant.
2. Inform mother of in house pump locations. Inform family of community resources to
obtain appropriate pump for use after discharge.
3. Obtain correct breast pump kit from unit.
4. Provide infant’s electronic medication labels or individualized labels with two unique
patient identifiers to label the breast milk.
5. Provide containers that are food-grade, BPA- and DEHP-free hard plastic or
glass with leak-proof lids.
HCA Lactation Consultant Workgroup
Final 7-28-10/8-31-10
6. Instruct mother to write the date and time of milk expression on the label.
7. Breast pumps will be wiped down with a hospital- approved germicide as follows:
a. Prior to each new patient use.
b. If a spill occurs
8. If internal contamination is noted, take the pump out of service.
B. Storage
1. Refrigerators/freezers for storing human milk should be labeled as such and should
be in a secure area.
2. Plug refrigerators/freezers used for human milk storage into emergency power
circuits.
3. Use individual patient labeled bin for patient’s own expressed milk and any allocated
pasteurized donor milk.
4. Human Milk freezers require alarms to notify staff if temperatures are out of range.
Consider use of remote alarm notification if freezer is not located in the immediate
area.
C. Handling
1. Thaw milk in refrigerator or in warm water insuring the water does not touch the
lid. Do not place in boiling water or microwave.
2. Prior to transfer of milk to any other feeding container (i.e. syringe, volufeed,
etc) and before administration, correct labeling will be verified by electronic medication
scanning system or two personnel.
3. Warm milk in container of warm water at bedside insuring the water does not
touch the lid. Do not place in boiling water or microwave.
4. For milk delivered via syringe pump:
a. use the shortest length of tubing possible
b. position with the syringe tip pointed up
c. change exchange tubing and syringe every four hours
5. Following the infant feeding, discard any unused, warmed human milk.
D. Documentation
1. Document date and times of freezing and thawing on human milk containers.
2. Document parent education on patient record.
3
Document that infant’s name and medical record number were verified between
original container label and infant band by two personnel or electronic medication
scanning system before preparation or administration of human milk.
4. Document any additives to human milk on the container label.
5. Document donor milk lot number in infant record.
HCA Lactation Consultant Workgroup
Final 7-28-10/8-31-10
E. Transporting and Shipping –
Patient will be provided the following information for transporting/shipping expressed milk:
1. Maintain the cold chain during transporting/shipping, especially for milk for
preterm infants.
2. Frozen gel pads are more suitable than ice cubes to keep milk cold or frozen.
(Freshly expressed milk can safely be stored for up to 24 hours in a cooler with
frozen gels packs)
3. For overnight shipping:



Pack frozen milk tightly into a cooler or appropriate container; filling all empty
space
(If packing frozen milk to ship overnight, fill any extra space in the cooler
to insulate the milk [crumpled paper works well to insulate milk]).
(Packing with sufficient insulation and putting the milk containers close
together will usually keep the milk frozen for about 24 hours although the
outside temperature may affect the actual length of time the milk will stay
frozen)
Do not use wet ice.
Use small amounts of dry ice ( less than 5 lbs) if there are any concerns that
the milk might thaw due to extremely warm temperatures or due to milk
containers that are less than half full.
Note: Dry ice is a hazardous substance. Shipping companies require special labeling
of the containers, may limit the amount of dry ice. Dry ice should never be used in coolers
transported in a car because it gives off carbon dioxide.
V. REFERENCES
Human Milk Banking Association of North America, Inc. (2005). Recommendations for Collection
Storage, and Handling of a Mother’s Milk for her own Infant in the Hospital Setting. West Hartford,
CT: HMBANA.
Centers for Disease Control and Prevention. (1994) Guidelines for Preventing Transmission of
Human Immunodeficiency Virus through Transplantation of Human Tissue and Organs
HCA Lactation Consultant Workgroup
Final 7-28-10/8-31-10