NURSING PATIENT CARE POLICY & PROCEDURE
May 20, 2016
Amended: Oct. 28,
Nursing Manual (Red)
Policy #: 8.28AP
Title: Human Milk Collection and Storage
(Adult & Pediatric)
To provide safe handling of human milk in the hospital setting.
A. Breastfeeding and human milk are the preferred feedings for all infants, including
those who are premature and hospitalized.
B. Hospital practices should encourage and support the initiation and continuation of
breastfeeding and use of human milk.
C. In circumstances where illness or maternal/neonatal separation prevents
breastfeeding, expression of human milk through pumping should be established
early. Continued pumping support should be provided until breastfeeding can be
D. Human breast milk is a body fluid and all aspects of the UWHC Bloodborne
Pathogens Exposure Control Plan apply.
E. All nurses working with infants and lactating mothers should possess basic skills /
knowledge of resources to support breastfeeding and pumping of expressed
human milk. These skills include:
1. Obtaining a hospital grade breast pump.
2. Facilitating breast pump assembly and pumping initiation.
3. Educating parents on expressed milk collection, storage, and transport,
including proper labeling while in the hospital.
4. Facilitating breastfeeding by assessing readiness cues, latch, nutritive
suck/swallow, and completion cues.
5. Assist mother with basic repositioning and comfort.
A. BPA-free, single use, hard plastic collection bottles, which allow human milk to
be pumped directly into the container in which it will be stored.
B. Clean gloves
C. Labels for containers
D. Milk storage bins
E. Hospital Grade Dual Electric Breast Pump (order via electronic health record
F. Human milk collection kit for double pump 67340S (Central Services [CS] Item
G. Designated refrigerators and freezers for storage
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H. Milk warmer
I. Steam quick clean bag (CS Item Number 4012592)
A. Obtaining a Lactation Consult
1. Lactation consults may be needed for the following reasons:
a. Prematurity (less than 37 weeks)
b. Low birth weight (less than 2,500g)
c. Difficult latch
d. Infant weight loss (greater than 10% of birth weight)
e. Difficulty with establishing milk supply
f. Unresolved sore/cracked nipples
g. Multiple gestation
h. Infant anomaly or neurological impairment
i. Critically ill infant who is NPO (receiving nothing by mouth)
j. First time breastfeeding mother
k. Separation of infant and mother during hospitalization
l. Pain during breastfeeding
m. Neonatal hyperbilirubinemia requiring phototherapy
n. Maternal history of breast surgery or gastric bypass
o. Maternal history of mastitis or persistent plugged ducts
p. Maternal request
B. Parent Education
Parents should be instructed on breastfeeding, pumping and human milk handling.
The following parent education information should be provided:
a. Breastfeeding is preferred if infant’s medical condition allows.
Pumping after the feeding may be necessary to facilitate emptying
of breasts in order to maintain or increase mother’s milk supply.
b. Refer to the following:
i. American Academy of Pediatrics (AAP) patient education
materials (see AAP website link on the Learning Center
website on U-Connect)
ii. Health Facts For You (HFFY) 7499, Common
a. Refer to the following for instructions on setting up and caring for
the breast pump:
i. HFFY 7563, Using and Cleaning the Symphony Breast
ii. HFFY 7498, Hands-on Pumping: Helps Mothers Make
iii. HFFY 7633, Providing Milk for Your Baby
3. Human milk handling
a. Parents should be instructed on collection, storage, labeling,
transporting, and administration of human milk (see below).
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a. Hospital pumps should be cleaned with approved sanitizing wipes
before and after each use.
b. Mothers should wash hands with soap and water or hand gel prior
c. A new collection bottle, to express milk directly into, should be
used with each pumping session.
d. Use colostrum containers for small volumes being pumped.
e. Advance to larger size containers to allow space for expansion of
milk with freezing.
f. All pump parts coming in contact with expressed milk should be
cleaned with dish soap and hot water after each pump and allowed
to air dry.
g. Pump parts coming in contact with expressed milk should be
sanitized daily using steam clean bag.
h. Mothers should be instructed to pump for 20 minutes at least eight
(8) times in a 24-hour period.
i. Encourage breast massage, breast compression and hand
expression, or “hands-on pumping” to increase volumes expressed.
j. Mothers of premature infants can be advised to separate pumped
milk into smaller containers to avoid wasting expressed milk.
D. Collection and Storage
a. Parents should be provided with bar-coded labels. Parents are then
responsible for applying these labels to expressed milk. The date
and time milk was expressed should be written on the label.
Unlabeled milk will be discarded.
b. Milk expressed prior to admission
i. Containers of milk with outside hospital labels should be
re-labeled with new bar-coded patient labels in the presence
of the mother. If the mother is not present, but outside
hospital labels are intact with patient identifiers and
date/time pumped, the containers may be re-labeled with
dual verification. This could be any combination of two (2)
RNs or milk lab nutrition technicians.
a. It is essential that human milk remain chilled or frozen during
transport to and from home.
i. It is preferred to transport in a chilled state if the fresh milk
can be readily used for infant’s feeding.
ii. If it is unlikely that milk will be used within 96 hours of
expression, human milk should be frozen at home,
transported frozen and stored in a designated hospital
b. Human milk should be transported to and from home in a cooler or
insulated bag using chemical gel packs, not ice.
c. If frozen milk will be in transit for more than 18 hours, the use of
dry ice is recommended.
a. Refer to the Human Milk Storage and Use Guideline in the related
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section on U-Connect.
b. During the milk lab’s operational hours, expressed milk should be
placed in unit based refrigerated bin to be picked up by milk lab
staff. The milk lab will store and prepare human milk and formula
according to Clinical Nutrition Policy 1.9, Human Milk and
Formula Storage, Preparation and Distribution.
c. During the milk lab’s non-operational hours, expressed milk will
be scanned into the bar-coded tracking system by the nurse
clinician. The location entered should be unit-based refrigerator. If
the milk received is frozen, the nurse clinician or care team leader
will scan in the milk and store it in the milk lab freezer. Milk lab
staff will collect the milk the following day.
1. The milk lab will deliver 24 hours of prepared human milk for patient
feedings to the patient’s bedside or unit refrigerator.
2. The bar code software will have detailed information related to fortification
and expiration of the human milk.
1. The nurse clinician should verify feeding order and scan feeding barcode prior
2. If human milk is administered via tube, bolus feeding is recommended due to
decreased loss of fat, compared to continuous infusion.
3. If feeding is administered via syringe pump, use an off-set tip syringe, with tip
on top, and angled 25-40 degrees to avoid fat loss. Only the amount of milk
needed for a feeding should be warmed.
4. Do not administer human milk feedings in a buretrol or feeding bag due to
loss of fat.
1. Carry out the following procedure if a patient has received human milk from
someone other than the mother. (Excluding Pasteurized Donor Human Milk
a. Notify the following
i. Attending Provider
ii. Care Team Leader
iii. Nurse Manager
iv. Infection Control
b. Complete a Patient Safety Net (PSN) and document event in a
progress note in the medical record.
c. The attending provider and Medical Director of Infection Control
will notify both families regarding misadministration and any
follow-up care. This communication will be documented in the
H. Downtime Procedure or Procedure for Units not Using Bar Coded Feeding
1. A label should be affixed to all expressed human milk prior to refrigeration or
freezing. Label should include the following:
a. Patient name
b. Patient medical record number
c. Date and time milk pumped
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d. Date and time milk frozen (if different than time pumped)
e. Date and time of thawing if applicable
i. Type and amount of fortification
ii. Date and time of fortification
2. A two-person verification (i.e., milk technician, RD, RN, etc.) is required
prior to all human milk administrations. Document that verification has been
performed in the electronic health record (EHR). Put the name of the second
person in the comment section of the type of food/infant nutrition row in the
3. Verification includes the following:
a. Patient name
b. Patient medical record number on patient identification band and
c. Assess that human milk feeding solution is not expired (see Human
Milk Storage and Use Guideline in the “Related” section on U-
d. Order verification: ensure correct feeding solution
I. Discharge, transfer or death of a patient receiving human milk
1. Discharge and Transfer
a. At the time of discharge or transfer, all stored human milk should
be obtained from the hospital freezer.
b. Milk should be signed out using bar-code software, or dual
verification during downtime. During downtime a note should be
placed in the patient’s medical record indicating number of bottles
signed out and the two people (RN or milk lab nutrition technician)
performing dual verification.
c. Milk should be transported in a cooler with chemical gel packs or
dry ice (see section on “transporting”).
2. Lactation Suppression
a. Refer to HFFY 7488, How do I Stop Breastfeeding or Pumping.
a. Mothers may choose to donate expressed breast milk if they are
certain their supply exceeds their infant’s needs or after a neonatal
b. An international board certified lactation consultant (IBCLC),
certified lactation counselor (CLC), or lactation resource nurse can
facilitate milk donation to a Human Milk Banking Association of
North America (HMBANA) milk bank.
c. Donation of milk requires a mother to complete a health
questionnaire and a blood test.
J. Pasteurized Donor Human Milk (PDHM)
1. The milk bank will use PDHM from an accredited HMBANA milk bank.
2. Indications for the use of PDHM:
a. All infants less than 2,000 grams birth weight. For multiple births,
if at least one multiple’s birth weight is less than 2,000 grams.
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b. Those who are extremely low birth weight (ELBW) and/or born at
23-26 weeks gestation should use pre-term donor milk as available
for the first four (4) weeks of life.
c. History of necrotizing enterocolitis (NEC) or other gastrointestinal
d. Infants with congenital heart disease
e. Post-surgical nutrition (Patent Ductus Arteriosus [PDA] ligation,
bowel surgery, etc.)
f. Significant feeding intolerance with infant formula(s)
g. Malabsorption syndromes
h. Absent or insufficient lactation
i. Immunodeficiency disorders
j. Illness in mother requiring temporary interruption of breastfeeding
k. Other indications according to clinician’s discretion and must
consult with Registered Dietician prior to use
3. A parent must sign the “Agreement to Use Donor Human Milk Provided by a
Donor Human Milk Bank (UWH 301580)” prior to use of PDHM.
4. An order must exist for the use of PDHM before feeding administration.
5. Clinical Nutrition stores PDHM in the Milk Lab. Please refer to Clinical
Nutrition Policy 1.9 Human Milk and Formula Storage, Preparation and
6. Please refer to Neonatal Enteral Nutrition Guidelines for weaning instruction.
7. Use of Prolacta
a. Prolacta is a human milk fortifier made from concentrated PDHM and
fortified with minerals intended for those with birth weight less than
b. Please refer to Neonatal Enteral Nutrition Guidelines for additional
qualifiers and weaning details.
8. The same collection, storage, distribution, and administration of expressed
human milk apply to PDHM and Prolacta.
K. Contraindications to Breastfeeding
There are few situations in which a mother’s own milk would not be suitable for
her infant. Breastfeeding and use of human milk would be contraindicated or
needs further assessment in the following circumstances:
1. Human Immunodeficiency Virus (HIV), Human T-Cell Lymphotrophic Virus
(HTLV) I or HTLV II and untreated brucellosis are absolute contraindications
for breastfeeding and expression.
2. Maternal infectious conditions where breastfeeding is contraindicated, but
expressed breast milk can be used. Contact Infection Control with questions.
a. Untreated Tuberculosis
b. Active Herpes Simplex lesions on breasts
d. H1N1 (until afebrile)
3. Maternal substance abuse with the following (adequately nourished, narcotic
dependent mothers can be encouraged to breastfeed if they are enrolled in a
supervised opioid maintenance program and have negative screening for HIV
and illicit drugs):
a. Illicit drug use of any type in the 30-day period prior to delivery
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b. Positive maternal toxicology testing for drugs of abuse
c. Unwillingness or inability to engage in substance abuse treatment
d. Women who demonstrate behavioral qualities or other indicators
of active drug use
e. Women who are not willing to disclose their doses of prescribed
a. Mothers who are receiving anti-metabolites, chemotherapy,
radioactive isotopes and certain other medications. Decisions to
refrain from breastfeeding and pumping human milk should be
made in collaboration with maternal provider.
b. For an up-to-date reference on drugs and lactation, refer to the
“LactMed” website (http://toxnet.nlm.nih.gov/cgi-
V. PROCEDURE FOR LACTATING PATIENT OR PRIMARY SUPPORT NOT
LOCATED AT THE AFCH
A. Collection and Storage for Lactating Patient or Primary Support on University
Hospital (UH), and The American Center (TAC) inpatient unit and in
Emergency Departments (ED).
1. Lactating women who are pumping and are either admitted as a patient or are
the primary support of a patient at UH, UH ED and TAC ED will be provided
an insulated cooler with four ice packs to store breast milk. Breast milk can be
stored in the coolers with frozen ice packs for 24 hours.
2. Mothers pumping for a sibling of a patient hospitalized at American Family
Children’s Hospital (AFCH):
a. RN will provide mother with Health Link labels of the child that is
b. Have the mother date/time bottles and write her name on the label.
c. Milk will be stored in the breast milk refrigerator on unit. Milk Lab
staff will check expirations daily and if freezing is needed milk
will be placed on bottom shelf in Milk Lab freezer.
3. Women should be encouraged to store milk at home. In the event that the
person lives too far away, breast milk will be frozen and stored in the milk lab
4. The RN will call the milk lab at 890-9645 (for locations at UH or AFCH only)
to notify them of patient’s (woman or the patient she is supporting) name and
location. If it is during the operating hours of the milk lab, a tech will tube an
insulated cooler and four frozen ice packs to the unit. If the milk lab is closed,
leave a voicemail indicating the name and location. Then call the NICU (890-
9600) to request a cooler and ice packs. RN or Milk Lab Staff will have
lactating mother complete and sign the “Human Milk Storage Agreement”
(Document 301678, available on U Connect) and will return signed document
to AFCH Milk Lab.
MILK LAB HOURS
Monday – Friday 8:00 am – 6:00 pm
Saturday & Sunday 8:00 am – 4:30 pm
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5. The RN will put two ice packs in the unit freezer and leave two ice packs in
the cooler. Ice packs stored in the freezer should be kept in a Ziploc bag with
a label containing the name of the patient currently admitted at the UW Health
facility and, if different, the name of lactating woman written on label. When
the two ice packs in the cooler start to thaw, the ice packs should be switched
out with frozen packs.
6. Expressed milk should be handled and stored in bottles as directed above.
7. Once the milk lab is notified, a tech will come to the room daily at 4:00 pm to
pick up milk. This milk will be taken to the milk lab to be frozen. All bottles
should be labeled with the patient’s Health Link label and, if different, the
name of the lactating woman. The person expressing the milk should be
confirming the label is correct and writing a time and date pumped. The milk
lab staff will not accept milk that is not properly labeled.
8. The lactating woman (or other designee) will be responsible for going to the
milk lab at the time of discharge to pick up frozen milk. The person picking
up milk will be responsible for bringing an adequate sized cooler to transport
the milk out of AFCH. The tech will confirm the patient’s name on the bottles
with the person. Once the name is confirmed, the tech will visually check each
bottle and hand the bottle to the person to double check. Once all milk has
been checked out, the person taking the milk home will sign a form stating
that milk was received and the name was double-checked.
VI. UWHC CROSS REFERENCES
A. Agreement to Use Donor Human Milk Provided by a Donor Human Milk Bank
(found on U-Connect)
B. Bedside Hangtime Practices for Infant Feedings (see Related section on U-
C. Breast Feeding Diary (see Related section on U-Connect)
D. Breast Pumping Log (see Related section on U-Connect)
E. Bloodborne Pathogens Exposure Control Plan, Revised July 2012 (on U-Connect)
F. Clinical Nutrition Policy 1.9 Human Milk and Formula Storage, Preparation and
G. Health Facts For You (HFFY) 5985, Choosing a Breast Pump
H. HFFY 7488, How Do I Stop Breastfeeding or Pumping?
I. HFFY 7498, Hands-on Pumping: Helps Mothers Make More Milk
J. HFFY 7499, Common Breastfeeding Concerns
K. HFFY 7563, Using and Cleaning the Symphony Breast Pump
L. HFFY 7633, Providing Milk for Your Baby
M. Human Milk Storage and Use Guideline (see Related section on U-Connect)
N. Learning Center Website (on U-Connect)
A. American Academy of Pediatrics (2012). Breastfeeding. Policy Statement
Breastfeeding and the Use of Human Milk. Pediatrics, 129(3), e827-841.
B. Academy of Breastfeeding Medicine (2009). Clinical Protocol #4: Mastitis.
Breastfeeding Medicine, 3(3), 177-180.
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C. Academy of Breastfeeding Medicine (2009). Clinical Protocol # 20:
Engorgement. Breastfeeding Medicine, 4(2), 111-113.
D. Academy of Breastfeeding Medicine (2009). Clinical Protocol #21: Guidelines for
breastfeeding the drug dependent woman. Breastfeeding Medicine, 4(4), 225-228.
E. Academy of Breastfeeding Medicine (2009). Clinical Protocol #22: Guidelines for
management of jaundice in the breastfeeding infant equal to or greater than 35
weeks’ gestation. Breastfeeding Medicine, 5(2), 87-93.
F. Best Practices for Expressing, Storing and Handling Human Milk: In Hospitals,
Homes, and Child Care Settings. HMBANA Book (3
G. Committee on Fetus and Newborn (2008). Hospital Discharge of the High Risk
Neonate. Pediatrics, 122(5), 1119-1126.
H. Henderson, G., Anthony, M. Y., & McGuire, W. (2007). Formula milk versus
maternal breast milk for feeding preterm or low birth weight infants. Cochrane
Database Syst Rev, (4), CD002972.
I. Indiana’s Mother Milk Bank. http://immilkbank.org/
J. Kent, J. C., Prime, D. K., & Garbin, C. P. (2012). Principles for maintaining or
increasing breast milk production. Journal of Obstetric, Gynecologic & Neonatal
Nursing, 41(1), 114-121.
K. Parker, L. A., Krueger, C., Sullivan, S., Kelechi, T., & Mueller, M. (2012). Effect
of breast milk on hospital costs and length of stay among very low-birth-weight
infants in the NICU. Adv Neonatal Care, 12(4), 254–259.
L. Patel, A. L., Johnson, T. J., Engstrom, J. L., & et al (2013). Impact of early human
milk on sepsis and health-care costs in very low birth weight infants. J Perinatol.
M. Robbins, S. T., & Meyers, R. (2011). Infant Feedings: Guidelines for preparation
of human milk and formula in health care facilities (2
Ed.). American Dietetic
N. Slutzah M., Codipilly, C. N., Potak, D. & et al (2010). Refrigerator storage of
expressed human milk in the neonatal intensive care unit. The Journal of
Pediatrics, 156, 26-28.
O. Sullivan, S., Schanler, R. J., Kim, J.H., & et al (2010). An exclusively human
milk-based diet is associated with a lower rate of necrotizing enterocolitis than a
diet of human milk and bovine milk-based products. J. Pediatr, 56(4), 562–
P. Vohr, B. R., Poindexter, B. B., Dusick, A. M., & et al (2006). Beneficial effects of
breast milk in the neonatal intensive care unit on the developmental outcome of
extremely low birth weight infants at 18 months of age. Pediatrics, 118(1), e115–
Q. Vohr, B. R., Poindexter, B. B., Dusick, A. M., & et al (2007). Persistent beneficial
effects of breast milk ingested in the neonatal intensive care unit on outcomes of
extremely low birth weight infants at 30 months of age. Pediatrics, 120(4), e953–
R. Wisconsin Association for Perinatal Care (WAPC) (2013). Newborn Withdrawal
Project Methadone Toolkit. Retrieved from,
VIII. WRITTEN BY
Clinical Nurse Specialist, Neonatal Intensive Care Unit (NICU)
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IX. REVIEWED BY
American Family Children’s Hospital (AFCH) International Board Certified
AFCH Practice Council
Certified Pediatric Nurse Practitioner/CNS, Pediatric Intensive Care Unit (PICU)
Clinical Nurse Specialist, General Pediatrics
Clinical Nurse Specialist, PICU
Clinical Nutritionist, Clinical Nutrition
Infection Control Practitioner
Nurse Manager, NICU
Nursing Patient Care Policy and Procedure Committee, May 2016
Beth Houlahan, DNP, RN, CENP
Senior Vice President Patient Care Services, Chief Nursing Officer