Approved by: Gail Cameron Director, Maternal, Neonatal & Child Health Programs Human Milk Neonatal Nursery Policy & Procedures Manual : August 2012 Next Review August 2015 Dr. Ensenat Medical Director, Neonatology Purpose Policy Statement Applicability Policy Elements Mother s milk is the preferred milk to feed babies. In addition to providing nutrition designed for a human infant, it contains many bioactive and immune factors that provide antimicrobial and antiinflammatory protection against infection and modulate the infant s immune system. However, mother s own milk (MOM) may not be available in sufficient quantities when the infant should start receiving milk feeds. Use of formula feeds in the at-risk population is associated with more complications, so it is desirable to provide donor human milk (DHM) until MOM is available or the at-risk period has passed. The goal is to ensure that at risk infants and infants whom parents wish to have human milk feeds receive human milk for enteral feeds in a safe and timely manner. Human milk is a body fluid and an infant must receive the human milk that was ordered due to the risk of pathogen transmission inherent with body fluids. Human milk will be collected, prepared, stored, and administered according to the procedure outlined in the Human Milk Management Procedure. DHM will be provided for at-risk infants when MOM is not available with a physician/nnp order and signed consent of the parents. DHM will be administered to infants without access to MOM when parents provide access to DHM. All Covenant Health Employees 1. Identification of At-Risk Infants DHM is considered for infants who do not have MOM available. The following criteria can help identify those infants who should receive DHM if a parent or guardian agrees: a) Gestation less than 33 completed weeks b) Intrauterine Growth Restriction less than or equal to the 3 rd percentile c) Initiation of enteral feeds post confirmed Necrotizing Enterocolitis d) Multiples, where one of the infants is receiving DHM Utilization of DHM for all infants is determined on a case by case basis. The appropriateness of DHM will be discussed by the health care team and this discussion should include the parent(s) or guardian(s). 2. Verification of Identity 2.1 Verification of the identity of the human milk shall be carried out at all four stages of the process, ( I.E. Collection and labelling, storage, retrieval, and administration/feeding) in accordance with the safe practices identified in the Human Milk Management Procedure. 2.2 If there is any discrepancy in the verification of the identity of the patient or accuracy of the information on the human milk label, the milk must be discarded. 3. Donor Human Milk (DHM) 3.1 Pasteurized donor human milk obtained from an approved source (i.e., milk bank), according to the Human Milk Banking Association of North America (HMBANA) guidelines, shall only be dispensed for administration/feeding following a written prescription or order from the infant s Most Responsible Health Practitioner and written consent from a parent or guardian.
Page 2 of 5 3.2 If a parent/guardian chooses to procure and bring in banked donor milk, she/he is responsible to provide documentation from an approved source (i.e. milk bank), as per the HMBANA guidelines, indicating that the milk has been properly collected, stored, pasteurized, and cultured in accordance with the Canadian Food Inspection Agency. If the documentation related to the source is not available, Health Service Providers and/or the infant s Most Responsible Health Practitioner shall present information to the family regarding the potential risks of viral transmission and harm to the infant. If the parent/guardian still chooses to use the milk, she/he will then assume responsibility for the risks and sign consent. The Most Responsible Health Practitioner will write a prescription or order and document that the parent/guardian has been informed of the risks. 4. Enteral Feeding Equipment and Supplies Parenteral syringes shall not be used to prepare, measure, or administer human milk intended for oral and enteral routes. Supplies, including single use syringes and extension tubing, designated specifically for enteral administration only must be used for enteral feeds. Syringe pump electronic labelling must be used to identify the solution as enteral feed. 5. Family/Guardian Participation Covenant Health is committed to ensuring that families/guardians are partners in the processes of care which includes active involvement for the safe management and handling of human milk. 6. Co-Signer The signature of a family/guardian for the purposes of verifying the label of human milk with the infant s identification band does not transfer liability from the Organization to the family/guardian for any adverse events as a result of the verification process. 7. Education 7.1 Health Services Providers caring for breastfeeding infants and families/guardians and/or handling human milk must be provided with education on safe management of human milk. 7.2 Ideally, the education of families/guardians regarding safe management of human milk shall occur upon admission and orientation to the care unit. 7.3 Education for both the Health Services Provider(s) and the families/guardians shall include: The role and responsibilities of the family/guardian as a partner on the health care team related to safe human milk management; The requirements and process for an Independent Double Check of human milk label with the infant s identification band if medication / additives have been added to the human milk; The process and requirement for a Health Services Provider and one of the following: a second Health Services Provider, or family/guardian to act as a Co-Signer, as identified in the safe practises of the Human Milk Management Procedure. Information about the risk of viral and other pathogen transmission, and the procedures to follow to ensure the safe management and handling of human milk during the infant s stay. Safe management includes adherence to Infection Prevention and Control (IPC) Routine Practices and Hand Hygiene Protocols; and Sensitivity to cultural, language and literacy differences and related challenges.
Page 3 of 5 7.4 Health Services Providers on a leave of absence, or otherwise away from their workplace for a time period extending 12 months must be provided education on safe management of human milk as part of orientation at the time of their return to work. 8. Documentation All processes, interventions and family/guardian teaching shall be documented in the Patient s health record. 9. Adverse Events If an infant receives, or the potential exists for the infant to receive unintended human milk from a source other than his/her own mother or donor human milk that is not designated for that infant, then this is deemed a Reportable Adverse Event. 9.1 The Infant receives unintended human milk: a) The charge nurse and the Most Responsible Health Practitioner must be notified immediately and the Breast Milk Incident Procedure must be followed; b) Both the Donor Mother and the infant s family/guardian must be notified of the adverse event following the process outlined in the Breast Milk Incident Procedure and the Covenant Health Disclosure of Adverse Event, Close Calls and Hazards (Policy No. III-40) 9.2 The infant, the family/guardian and/or a Health Services Provider was involved in a near miss with the administration of unintended human milk: a) The charge nurse should be notified immediately, and there should be a discussion about next steps and reporting the incident in the Reporting Learning System (RLS). 10. Audit Audits of practices related to safe human milk management and results reported should be conducted monthly with review of RLS reports and storage temperature log reviews/incidents by the unit manager or designate. Definitions Co-Signer means Health Services Provider s signature and one of the following: a second Health Services Provider, or infant s mother, father, or guardian is necessary as one of the double signatures required in the Human Milk Management procedure. Donor Human Milk (DHM) comes from an accredited Human Milk Bank which follows guidelines set by Human Milk Banking Association of North America (HMBANA). DHM is collected from lactating women who have met rigid screening criteria that includes a medical and lifestyle history, blood testing for HIV, HTLV I and II, Hepatitis B&C, and syphilis. Donated milk is pasteurized and cultured to ensure the safety of all recipients. The milk is frozen for storage and transport as per HMBANA guidelines. Family refers to one or more individuals identified by the Patient as an important support and who the Patient wishes to be included in any encounters with the healthcare system, including, but not limited to family member, legal guardians, friends, and informal caregivers Covenant Health Disclosure of Adverse Event, Close Calls and Hazards (Policy No. III-40). A Mature Minor may be included as Family where applicable. Independent Double Check: a second practitioner or Health Services Provider, in the presence or absence of the first practitioner, individually performs preparatory calculations or verification of identity checks and arrives at his/her own conclusion.
Page 4 of 5 Most Responsible Health Practitioner: means the Health Practitioner who has responsibility and accountability for the specific Treatment/Procedure(s) provided to a Patient and who is authorized by Covenant Health to perform the duties required to fulfil the delivery of such a Treatment/Procedure(s) within the scope of his/her practice. Mother s Own Milk (MOM) Human milk collected by a lactating mother to feed her own infant. Patient: means all individuals who receive or have requested health care or services from Covenant Health. This term is inclusive of residents and clients. Reportable Adverse Event: is an unexpected occurrence that reaches the patient (Covenant Health Disclosure of Adverse Event, Close Calls and Hazards: Policy No. III-40) and must be reported to the designated charge nurse and the most responsible physician for action. Donor Mother: The woman who expressed milk was unintentionally given to an infant other than her own. Related Documents Adapted with permission from Stollery Children s Policy and Procedure Manual: http://www.intranet2.capitalhealth.ca/nicu/pages/policiesprocedures/policiesprocedures_new.htm Human Milk, RELATED POLICIES AND PROCEDURES Human Milk Management Breast Milk Incident February 2011 Covenant Health Disclosure of Adverse Event, Close Calls and Hazards: Polico No. III-40 October 2011
Page 5 of 5 Signing Original Signed July 13, 2012 GAIL CAMERON DIRECTOR MATERNAL, NEONATAL & CHILD HEALTH PROGRAMS COVENANT HEALTH GREY NUNS & MISERCORDIA HOSPITALS DR. SANTIAGO ENSENAT MEDICAL DIRECTOR NEONATAL PROGRAM COVENANT HEALTH GREY NUNS HOSPITAL DATE Original Signed July 16, 2012 DATE