POLICY/PROCEDURE TITLE:
MOTHER’S MILK: COLLECTION,
STORAGE & PREPARATION
Women & Infant Services
RELATED TO:
[ ] Medical Center Policy (MCP)
[ x ] Nursing Practice Stds.
[ ] JCAHO
[ x ] Patient Care Stds.
[ ] QA
[ ] Other
[ ] Title 22
[ ] ADMINISTRATIVE
[x] CLINICAL PAGE 1 _ OF 4_
Effective date: 10/92
Revision date: 8/94, 11/96, 3/98,
6/98,7/01, 10/04, 10/05, 2/08
Reviewed: 3/08, 7/09
Unit/Department of Origin: ISCC
Other Approval: 11/12/92, 8/94, 2/04, 2/08
POLICY STATEMENT:
To provide guidelines for the collection, storage and handling of mother’s milk to optimize nutritional and
immunological protection while minimizing the chance of contamination or error. This will include timely
education and support of pumping to establish and maintain milk supply for mothers who plan on breastfeeding
but for some reason (prematurity or illness) are separated from their infants.
DEFINITIONS:
Fresh Milk:
Milk at room temperature at approximately 20º C (68 F) or
refrigerated at 4ºC
Frozen Milk: Milk held at approximately -20ºC (14 F) or -70ºC (-36 F)
Thawed Milk: Milk that has been previously frozen
EQUIPMENT:
1. Collection:
a. Electric breast pump
b. Pump kit
c. Sterile Storage Containers
d. Patient Labels
2. Storage:
a. Storage Bin in freezer with patient’s label for identification
b. Storage Bin in refrigerator with patient’s label for identification
c. Sterile containers
d. Labels with patient identification
e. Ink pen for labeling
3. Preparation/Fortification:
a. Cleaning spray
b. Paper towels
c. Gloves
d. Sterile Containers
e. Additives as ordered
f. Labels with patient identification
g. Pen for labeling
RESPONSIBLE PARTY: Nursing staff in the ISCC
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UCSD Medical Center
BREASTMILK: COLLECTION, PREPARATION, STORAGE & FEEDING
page 2
PROCEDURE:
1. Collection: See Policy: BREAST PUMP: ELECTRIC/MANUAL SET UP
a. Mothers who are inpatient at UCSD Medical Center and who wish to supply mother’s milk
and/or breastfeed their newborn, but who are separated from their infant during the first 12
hours of life, are assisted with pumping within 2 hours of the birth of their infant or at the time of
separation
b. Pump kit and instruction in collection and storage of mother’s milk are initiated within 2 hours of
the infant’s birth in Labor & Delivery and reinforced on admission to FMCC or PSCC unless the
mother is seriously ill
c. Mother’s milk is collected and stored in syringes or containers
d. A new container is used each time milk is pumped and collected
e. MOMS labels given to the family member will be verified by the family member including date of
birth, infant’s name, and medical number
f. Containers with mother’s milk will be labeled with MOMS label and the date and time of
collection
2. Storage:
a. Mother’s milk should be stored according to the guidelines outlined below
b. All milk should be labeled by the baby’s mother when pumped and brought immediately to the
ISCC if mother is in the hospital
c. If mother is pumping at home she should place milk in labeled containers in the refrigerator
d. Mother’s milk should be transported in an insulated cooler with iced gel pack
e. Mother’s milk from home should be given to RN or Nutrition Tech
f. Frozen mother’s milk from home should be transported in a manner to maintain frozen state.
g. In the ISCC there shall be a dedicated bin in both the refrigerator and freezer for each patient,
the bins are labeled with one of the infant and mother MOMS labels
h. RN or Nutrition Tech receiving mother’s milk should verify that each container is labeled with
mother’s MOMS label and date/time mother pumped
i. Mother’s milk that will not be used fresh may be frozen within 6 days
Mother’s Milk Storage Guidelines
Room Temperature
Refrigerator
Fresh milk (never frozen)
Thawed (previously frozen)
Freezer
(2 door refrigerator – not in the door)
Deep Freezer
3 hours
3 days
24 hours
3 months
12
months
3. Preparation:
a. Cleaning and maintenance of the milk preparation areas in the ISCC:
i. The designated milk preparation areas will be wiped down with an aseptic solution every
12 hours by the ISCC HUSC and logged on the tracking log at each location in nursery
“A” and “C.”
ii. The mother’s milk refrigerator will be cleaned inside on Sunday each week by the ISCC
HUSC and logged on the refrigerator temperature log.
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UCSD Medical Center
BREASTMILK: COLLECTION, PREPARATION, STORAGE & FEEDING
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iii. Breast pumps will be cleaned between patients’ use and clean plastic bag will be placed
over the clean pumps to keep them clean from dust between uses.
b. Thawing Frozen Milk:
i. Thaw mother’s milk in refrigerator or in warm water. Do not place in microwave or thaw
frozen milk at bedside. The thawing container should be changed daily and should be
labeled with patient label and date and time of initiation. After milk is thawed add date
and time of thawing to the label on the container(s).
ii. Thawed milk shall be used within 24 hours of thawing.
iii. When using a syringe, apply a red cap to open end prior to submersion in water.
c. Fortifying Breast Milk: A physician or NNP order is required to fortify human milk. When adding
Human Milk Fortifier (HMF), Neosure powder or protein supplement:
i. Measure mother’s milk into sterile container (what type?) and warm to room
temperature.
ii. Check the expiration date and name of the product on the individual packets before
using.
iii. Calculate the correct number of packets to be added to the milk volume as ordered by
physician/NNP
iv. Shake milk container well to distribute fat particles.
v. Add all additives as ordered to the correct volume of breast milk and shake well to mix
completely.
vi. Label the container to indicate that individual fortifying products were added, the caloric
value of the final mixture, date and time thawed and prepared.
vii. Use within 24hours of preparation.
4. Preparation of Feeding:
a. Care should be employed to use fresh colostrum and fresh milk when available and to use milk
in chronological order. If fresh mother’s milk is not available, oldest frozen milk available will be
used first.
b. Infants <30 weeks gestation born to Mothers that are CMV IgG positive or if status is
unknown must have all milk frozen for a minimum of 12 hours prior to feeding. This
process of freezing milk should continue until 30 weeks adjusted age.
c. Check physician’s order.
d. Clean hands thoroughly and prepare a clean surface on which to prepare milk and to handle
containers.
e. Remove baby’s milk from refrigerator.
f. Shake containers well to redistribute fat and nutrients.
g. All mother’s milk will be double checked by 2 licensed personnel at transfer from storage
container to delivery container, and documented on the patient care record. An identification
label (as stated above), will be placed the delivery container (syringe or volufeed) at the time
milk is transferred.
h. When using milk that has been thawed, verify the container for name, date and time thawed.
i. Gently shake and/or rotate the feeding container immediately prior to feeding.
j. Document in nursing flow sheet:
k. Type, volume, any additives, and method of feeding
l. Any residuals or emesis
m. Duration of feeding time
n. Infant tolerance of feeding
o. Second Licensed personnel will initial on the flow sheet in the appropriate column, confirming
container to correct delivery container with patient label including patient name and medical
record number as a double check.
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UCSD Medical Center
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REFERENCES:
Breastfeeding and the use of human milk. Pediatrics (2005) 115:496-506.
Human Milk Banking Association of North America (2005) Best Practices for Expressing, Storing and Handling
of Human Milk in Hospitals, Homes and Childcare Settings. Raleigh, NC HMBANA
Hale, TW, Hartmann, P. (2007) Hale and Hartmann’s Textbook of Human Lactation. 1st Edition Hale
Publishing, L.P. Amarillo Texas
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