Obtaining and Using Donor Milk in the NICU

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Obtaining and Using Donor Milk in the NICU

• Karen Strube RNC-OB, IBCLC
• Lactation Program Coordinator
• Wheaton Franciscan Healthcare All Saints

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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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Mothers own milk is preferred for infants in the
NICU

• 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 dont badger
  mothers or talk them into it we provide
  accurate information, document and communicate
  the mothers 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.

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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

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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)

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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)

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Recommendations Cont.

• 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 mothers 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
  1091926-1942

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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.

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HMBANA Locations
Operating Milk Bank
Developing Milk Bank
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Developing Local Milk Bank

• The Mothers 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.

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All Saints 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.

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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 877-829-7470. 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 info_at_milkbankwgl.org. 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 info_at_milkbankwgl.org.
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Donors

• Are healthy lactating women.
• Are mothers with an abundant milk
• supply or grieving mothers who
• donate their babys 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.

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Bereavement Donation

• Stored breast milk represents the mothers 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 babys 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.
•  
• Sincerely,
•  
•  

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Milk Processing
Scrubbing
Pooling
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Milk Processing
Pouring
Pasteurizing
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Milk Processing
Labeling
Microbial Testing
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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.

www.latrobe.edu/au/microbiology/table7.html
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Bacteriologic Testing

• After pasteurization, one bottle from each batch
  is sent for culture. If there is any growth, or
  contamination, the entire batch is discarded.

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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

1. Boyd et al., 2007 2. Sisk et al., 2008
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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
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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

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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 Bank4755 Kingsway Drive,
  Suite 120Indianapolis, IN 46205Phone (317)
  536-1670Toll-free 1 [phone]FAX (317)
  536-1676
• Contact
• Janice ORourke, Executive Directorjorourke_at_immb.
  org

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Guidelines For Use of PDHM

• Need Physician Order
• Need parental consent prior to use
• Will start MEFs 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 gt34 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

• 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.

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Process Cont.

• 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.

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Preparation and Feeding

• 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 infants 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 MEFs from the
  volufeed (not from the unit bottle).

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Preparation and Feeding Cont.

• 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 infants
  sticker and identify the milk as PDHM.
• PDHM can be fortified as per current NICU
  protocol.
• Enter the infants 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

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PDHM Log Book

• Pasteurized Donor Human Milk (PDHM)
• Log
• Book
•  
•  
• Wheaton Franciscan Healthcare All Saints
• St. Lukes Health Pavilion NICU
• (stored in Nutrition Room)

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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

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Donor Human Milk Receiving Form/Log
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Donor Milk Usage Form/Log
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Donor Human Milk Recall Form/Log
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Keeping enough milk stockedAvoiding Wasted
MilkClarification of policyDonor Milk vs.
Mothers Own Milk Storage guidelinesWho does
what? RN, Lactation Consultant

• Challenges Along the Way

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Whats 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 mothers milk
  supply is established.
• Establishing the ability of donor mothers to drop
  off milk donations at any Wheaton facility to be
  transported to All Saints 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 infantsBanked donor milk
  should be promoted as a standard component of
  health care for premature infants.

Arslanoglu, Ziegler, Moro., 2010
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References

• 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), 347-351.
• 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), 172-177.
• 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, OConnor DL,
  Field CJ. (2011). Effect of pasteurization on
  immune components of milk implications for
  feeding preterm infants. Appl Physiol Nutr
  Metab. 2011 Apr36(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.

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References Continued

• 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)1281186-1191.
• 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.
  doi10.1542/peds.2004-1833.
• Sisk, P.M., Lovelady, C.A., Dillard, R.G.,
  Gruber, K.J., OShea, 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., OShea, 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.
  doi10.1542/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.

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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