Handling of Breastmilk

1. Is Breastmilk a Biohazard?

According to the CDC breastmilk “is not considered a biohazard and no special precautions exist for the handling of expressed human milk, nor does the milk require special biohazard labeling. The Universal Precautions to prevent the transmission of human immunodeficiency virus (HIV), Hepatitis B virus, and other blood-borne pathogens do not apply to the handling of human milk.”

This statement is, however, made in the context of breastfeeding and HIV and other blood-borne pathogens with regards to handling. It does not refer to milksharing situations and consumption of donor milk, nor does it imply that screening and/or pasteurizing are unnecessary in a milksharing situation.

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2. How can breastmilk be expressed?

Always make sure that supplies are clean and wash your hands before handling breastmilk

Breastmilk can be expressed by hand, manual pump or electric pump. Following are suggested steps for properly and safely expressing breastmilk:

  • Before beginning, make sure that your supplies are clean and dry.
  • Vigorously wash hands, fingers, forearms and under nails with soap and warm water for 20 seconds, dry hands with paper towel and then use paper towel to turn off faucet. Read these instructions for more information on proper hand washing techniques.
  • Inspect your breasts and make sure that the nipples are not cracked and bleeding and that there are no open sores, lesions or blisters on the breast. If so, do not donate at this time. Please read this section for more information on open sores, blisters, and/or bleeding cracks on the skin.
  • Follow the pump’s instruction manual or consider expressing by hand. Please read this link for expressing tips and pumping information. This video is a good tutorial on how to express breastmilk by hand.
  • Properly label the storage container with name and date and place in the freezer or refrigerator.
  • After pumping and storing, wash and properly store the supplies.

Pumps can be bought or rented, either by the donor or by the recipient, depending on their arrangement with each other. No difference has been found in bacterial contamination when using a pump or manually expressing. Please see this Protocol of the Academy of Breastfeeding Medicine for more information.

Please note that there are two kinds of pump systems: open system pumps and closed system pumps. Open system pumps are not suitable for multi-person usage.

After the use of drugs, certain medications and alcohol, breastmilk may need to be expressed and discarded. For more information please read ‘Drugs, medication, alcohol and the decision to discard breastmilk?

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3. How can breastmilk be stored?

Always make sure that supplies are clean and wash your hands before handling breastmilk.

Breastmilk can be stored at room temperature, in the refrigerator, in the freezer or in coolers depending on how long it needs to be stored. It can be stored in capped glass or plastic containers, specialized ‘breastmilk storage trays’ or in specialized milk bags.1

Always handle breastmilk with clean hands and follow the manufacturer’s instructions for properly cleaning your pump.

  • Pump into a clean bottle connected to the pump.
  • When finished expressing or the bottle is full, store directly in the bottle or transfer into an clean and approved breastmilk storage container.
  • The MayoClinic states: “You can add freshly expressed breast milk to refrigerated or frozen milk you expressed earlier in the same day. However, be sure to cool the freshly expressed breast milk in the refrigerator or a cooler with ice packs for at least one hour before adding it to previously chilled milk. Don’t add warm breast milk to frozen breast milk because it will cause the frozen milk to partially thaw. Keep milk expressed on different days in separate containers.”2
  • Store expressed milk in small amounts, and increase amount as a baby eats more per feeding. Freezing milk in small amounts (2-4 oz) is most convenient to avoid waste.
  • If milk is to be frozen for storage, this is best done immediately after expressing.
  • Previously frozen milk can be stored in the refrigerator for 24 hours.
  • Remember that breastmilk will expand when frozen, so do not overfill the container, especially if using a glass container.
  • Mark name, date, amount of milk, and age of baby on the container.
  • Storage bags should be stored carefully, away from other items in the freezer to avoid any damage. Laying storage bags flat for freezing is most space saving: simply stack them when frozen. Some mothers have made clever dispensers as well.
  • Please do not freeze milk in the door of the freezer as the temperature fluctuates too much.

Thawed, non heat-treated milk can be kept in the refrigerator for 24 hours. According to the USDA, “Once food is thawed in the refrigerator, it is safe to refreeze it without cooking.” In this protocol, Dr. Anne Eglash, M.D. writes: “At this time, there is little information on refreezing of thawed [fresh –ed.] human milk. Bacterial growth and loss of antibacterial activity in thawed milk will vary depending on the technique of milk thawing, duration of the thaw, and the amount of bacteria in the milk at the time of expression. At this time no recommendations can be made on the refreezing of thawed human milk.”

It is said that once breastmilk has been expressed, it is important not to shake it, especially if the milk is also to be frozen, because shaking denatures the shaped molecules of the protective proteins. We have however not found any evidence based research to support this claim. The research that does address shaking breastmilk evaluates mechanical shaking or so called vortex shaking.

For more information about storing breastmilk and which containers to use, please visit this page from the MayoClinic and this Protocol of the Academy of Breastfeeding Medicine.

Please see the section ‘How long can breastmilk be stored?’ for information on length of storage. If storing breastmilk in order to ship it, please see ‘How can breastmilk be shipped or transported.’

For recipients:
Upon receiving the breastmilk, store it in the freezer or in the refrigerator as given, or use within 6-8 hours depending on the need. More information can be found here.

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4. How long can breastmilk be stored?

Breastmilk can be kept at room temperature, in the refrigerator or in the freezer, depending on the need. Per Women’shealth and these CDC guidelines, breastmilk can be stored:

Location of storage Temperature Maximum recommended
storage time
Notes
Room temperature 16-29ºC (60-85ºF) 3-4 hours optimal
6-8 hours acceptable under very clean conditions3
Covered containers
Insulated cooler bag4 15ºC (59ºF) 24 hours Keep ice packs in contact with milk container
Refrigerator ≤4ºC (39ºF) 72 hours optimal
5-8 days under very clean conditions
Store milk in the back of the main body of the refrigerator
Freezer compartment inside refrigerator -15ºC (5ºF) 2 weeks
Freezer with separate doors from refrigerator ≤-17ºC (0ºF) Up to 6 months is best
Up to 12 months is acceptable
Store milk toward the back of the freezer.

Please note that in the freezer, foods are kept safe almost indefinitely and that these recommendations are for quality only.5

In ABM Clinical Protocol #8, the Academy of Breastfeeding Medicine Protocol Committee writes: “The basic principles of freezing dictate that frozen foods at -18C (0F) are indefinitely safe from bacterial contamination, although enzymatic processes inherent in food could persist, with possible changes in milk quality.”

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5. How can breastmilk be shipped or transported?

a. Introduction

The financial aspects of shipping a box of breastmilk to a recipient family are best arranged before the supplies are bought and the box is shipped. This can be done via online secure payment processors and/or by calling the courier and pay over the phone (for the shipping part).

Breastmilk can be shipped or transported in coolers or cooler shipping boxes, using ice, dry ice or gel packs.

For local transportation of breastmilk, keep the milk in a cooler and on ice, especially in hotter climates.

Recipients can generally pay for shipping costs via pre-paid shipping labels. Please call your local courier for more information on how to arrange this.

Overnight shipping and long distances are best done with dry ice and/or gel packs since regular ice melts quickly. For dry ice and gel pack shipping information, please visit this website and this website.

The courier used to ship the package will need to know that the content is a low risk biological product, and that the package contains dry ice. Shipping breastmilk generally does not require documentation or a permit, but each shipping company and country will have slightly different requirements, all based in law, especially when shipping internationally, so call and ensure all paperwork is filled out before going to the shipping center or the courier arrives.

For shipping across country lines, please inquire about the customs information of your country.

Air shipping
Special considerations apply when shipping dry ice packages by air: Dry ice is a hazardous material and as such it is regulated for shipment by the United States Department of Transportation (USDOT) and the International Air Transport Association (IATA). Regulations require that specific procedures must be followed when shipping dry ice.”

According to this website, “For air transport, the amount of dry ice per parcel is limited to five pounds or less, but it’s generally unlimited for ground shipments. Shipments containing dry ice must carry a Class 9 DOT miscellaneous hazardous material warning label, and must be clearly marked “Carbon Dioxide Solid, UN1845” or “Dry Ice, UN1845″. With five pounds of dry ice, the package would need to be delivered within 24 hours, as the recommendation for ordinary cooler use is 10 pounds per day. Biological material is often a dry ice shipment, which may have additional special requirements provided by the cold chain industry.”

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b. What kind of container is breastmilk stored in for shipping?

For basic safe storing information, please first see ‘How can breastmilk be stored?’

Fresh milk can be stored flat in (self-sealing) freezer bags, with ideally no more than 6 ounces per bag to ensure a uniform shape and freeze/thaw. When laying milk bags in the freezer, it is recommended to fold half an inch of the bag under to allow space for expansion without compromising the seal of the bag. This also provides a relatively uniform shape which makes packing easier. Do not freeze or store in the door of the freezer as the temperature fluctuates too much when opening the door.

Milk stored in plastic or glass bottles or some other type of hard container are best sealed tightly, with several containers placed in sealable freezer bags to ensure that breakage or leakage does not contaminate the entire shipment. Some form of cushion or padding may need to be added to ensure safety of transport.

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c. How can breastmilk be packed for shipping?

For a visual on how to pack breastmilk for shipping, please watch this video. A transcript can be found here. Also see these instructions for packaging and shipping breastmilk.6

On dry ice

Always handle dry ice in a well ventilated room. Dry ice vaporizes to carbon dioxide and can cause poisoning in enclosed spaces.
  • Please read these safety precautions.
  • Have ready: gloves and/or tongs, mallet or hammer, regular screw driver or ice pick for breaking up the block of dry ice, paper and paper bags (optional, for grouping milk and added insulation).
  • Determine the amount/weight of breastmilk to be shipped and purchase a fitting Styrofoam or other insulated cooler which does not have a complete sealing lid. It is important that dry ice is able to vent the carbon dioxide gas which results from warming. It is best to then place the cooler in a cardboard shipping box for ease of labeling and reduction of the chance of the lid being dislodged and losing the contents.
  • Locate the nearest dry ice dealer by asking at the local convenience store, grocery store etc. or by consulting the dry ice directory. Bring an appropriate sized cooler to carry the dry ice in. Ask the attendant for the appropriate amount of dry ice (see chart). Be sure to have the cooler and milk ready to pack as soon as possible so that the dry ice does not evaporate while preparing the milk.
  • Break up a small amount of dry ice into a flat sheet or into small chunks and spread evenly in the bottom of the cooler. Begin layering the milk evenly without packing tightly. Milk can be put in paper bags for easy grouping of milk by month or volume, for insulation and for easy taking out of the cooler. Place the oldest milk into the cooler first, and the freshest milk on the top. This way the oldest milk is placed into the freezer last and positioned to be used first while cutting down of the amount of handling and potential for thawing or damage.
  • If shipping a large quantity of milk, layer milk, dry ice, milk etc. to ensure that all the milk has an even freeze for the duration of shipment.
  • If the milk and dry ice do not fill the entire cooler (or if shipping glass bottles), loosely crumple packing paper or paper grocery bags and use it to fill in all remaining space to keep the milk securely packed and provide some additional internal insulation.
  • Break any remaining dry ice into small pieces. Spread or sprinkle it into the cooler, making sure that it is filling in the empty spaces/top of the cooler.
  • Once the dry ice, milk and any necessary packing is in the cooler, place the lid securely on the cooler. Placing a piece of tape across the top of the cooler (one across the length and one across the width, making an “X”) will secure the lid adequately for shipping. Do not seal the seam of the lid.
  • Place the cooler in the cardboard box, again loosely packing paper to fill any space that would prevent the cooler from shifting a lot within the box. Make sure that the top of the packing box is securely shut with heavy duty packing tape while still allowing movement of gas from within the cooler. If the shipping company does not provide a label for perishables, make one from a red piece of construction paper or note card. Clearly write “PERISHABLE – BREASTMILK” on a couple of labels and if using containers rather than bags, indicate which direction is up.

With Gel Packs

  • As with the dry ice packing, place a layer of frozen gel packs on the bottom of the cooler. Begin layering milk, starting with the oldest milk on the bottom, and the freshest milk on the top. This way the oldest milk is placed into the freezer last and positioned to be used first while cutting down on the amount of handling and potential for thawing or damage. If sending a large quantity of milk, alternate layers of frozen milk and gel packs. If there is space left in the top of the cooler or along the sides, place loosely crumpled paper in these spaces to secure the milk for shipping.
  • Place the cooler in the cardboard box, again loosely packing paper to fill any space that would prevent the cooler from shifting a lot within the box. Make sure that the top of the packing box is securely shut with heavy duty packing tape while still allowing movement of gas from within the cooler. If the shipping company does not provide a label for perishables, make one from a red piece of construction paper or note card. Clearly write “PERISHABLE – BREAST MILK” on a couple of labels and if using containers rather than bags, indicate which direction is up.

Below a picture of the end result, from FedEx’s “Packaging Perishable Shipments“:

For more dry ice and gel pack shipping information, please visit this website and this website. For home made gel packs, please visit this website.

For insulated shipping boxes in the US, please visit this website and this website.

For making you own box:

  • Create an insulated box with a styrofoam container and a cardboard box. Cut and tape the styrofoam box with duct tape if needed. Do not tape the lid shut!
  • Use styrofoam from an appliance store and cut to fit a box. Again, do not tape the lid shut!

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d. How much is being shipped?

The following table may help in estimating cost using dry ice, assuming the use of a Styrofoam cooler with a cardboard shipping box. (Weight in US units. Please use the converter on the right for metric units.)7

Please note that according to this website, “For air transport, the amount of dry ice per parcel is limited to five pounds or less, but it’s generally unlimited for ground shipments. Shipments containing dry ice must carry a Class 9 DOT miscellaneous hazardous material warning label, and must be clearly marked “Carbon Dioxide Solid, UN1845” or “Dry Ice, UN1845″. With five pounds of dry ice, the package would need to be delivered within 24 hours, as the recommendation for ordinary cooler use is 10 pounds per day. Biological material is often a dry ice shipment, which may have additional special requirements provided by the cold chain industry.”

How much is being shipped table

Table 1. Shipping weight estimates are given in pounds.

“For gel packs, as a generality use one pound per cubic foot per day. (Most gel packs come in 1/2 pound size but newer ones are up to 2 pounds.) This will be last for up to three days. For a longer time Dry Ice has to be combined to extend the gel packs with the possibility of freezing the goods briefly in the beginning.”8

Shipping rates can be calculated via the various shipping agencies. Within the US, please see:
UPS
USPS
FedEx
Amtrak (offers small package and ‘less-than-truckload’ shipping services between more than 100 cities.)

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e. Transit time

Frozen milk on dry ice that will be shipped within a state, province or region, or to a neighboring state, province or region, can be shipped by ground. Call the local couriers for more information. They can give specific times for delivering the package to them or at home pick up for same day shipping.

If the milk is shipped over a couple of state, provinces or country lines, or if there is a chance that the milk needs to be stored due to weather impediments, it is especially important that the milk be packed with dry ice and/or gel packs to prevent thawing.

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f. At the shipping center

At the shipping center, paperwork is filled declaring the amount of dry ice in the box and to identify it for special handling. Determine the type of shipping that will be used. By calling ahead, the shipping center will be able to advise as to what the best time of day for drop of is to make sure the package ships efficiently.

Please note that not all shipping centers are able to accept a package including dry ice, so be sure that you verify this ahead of time. The goal is to have the milk in transit as soon and as efficiently as possible. Having the breastmilk package sitting in a dock for hours only increases the risk for mishandling.

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6. How can breastmilk be thawed?

Breastmilk can be thawed in the refrigerator, in a container of (warm) water or under running (warm) water.

Please find proper thawing instructions at Woman’shealth and the CDC.

Please note that it is not advisable to defrost breastmilk in the microwave. As per CDC guidelines:

  • “Microwave ovens do not heat liquids evenly. Uneven heating could easily scald a baby or damage the milk.
  • Bottles may explode if left in the microwave too long.
  • Excess heat can destroy the nutrient quality of the expressed milk.”

Microwave heating can also cause a significant decrease in activity of anti-infective properties. This research concludes that “Microwaving appears to be contraindicated at high temperatures, and questions regarding its safety exist even at low temperatures.”

Thawed milk can be kept in the refrigerator for 24 hours. According to the USDA, “Once food is thawed in the refrigerator, it is safe to refreeze it without cooking.” In this protocol, Dr. Anne Eglash, M.D. writes: “At this time, there is little information on refreezing of thawed [fresh –ed.] human milk. Bacterial growth and loss of antibacterial activity in thawed milk will vary depending on the technique of milk thawing, duration of the thaw, and the amount of bacteria in the milk at the time of expression. At this time no recommendations can be made on the refreezing of thawed human milk.”

Please see ‘How can breastmilk be reused’ for further information.

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7. How can breastmilk be pasteurized at home?

When full screening is not available, donor health status is unknown, or to reduce the potential risks of exposure to HIV and/or other pathogens, breastmilk can be pasteurized at home.

  • Holder pasteurization

Holder pasteurization is considered the standard for human and cow’s milk pasteurization. It has been shown to inactivate pathogens while maintaining adequate nutritious properties. However, given its longer time-temperature curves, this method damages more of the antimicrobial factors of breastmilk than would flash pasteurization.

This method of pasteurization can be done by parents or caregivers on the stove top, or with a home pasteurizer kit for human milk. Some mothers may decide they want to buy commercial grade pasteurizers which are also available.

For an explanation on how to perform Holder on the stove top, please go here.

  • Flash-heating (FH)

Flash-heating is a low-tech method of pasteurizing breastmilk that was developed for HIV postitive mothers in developing countries who had no safe or affordable alternatives for feeding their infants.9

Studies by a research team lead by Israel-Ballard,10 have shown that FH breastmilk inactivates HIV and 4 common bacteria.

For an explanation on how to perform the Flash-heat method of pasteurization, please go here.

For more information on the different pasteurization methods see this section.

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Cooling down heat-treated milk
Cooked foods have a ‘danger zone,’ a temperature range from 60ºC/140ºF to 4ºC/39ºF where bacteria like to grow. It is therefore important to cool milk down quickly after it has been heated. Cooling the container in ice water is the quickest way to cool milk. Depending on the amount of milk, cooling it in the refrigerator is generally not recommended as the milk will cool unevenly, leaving some milk too warm for too long. Please know that not all glass is suited for heating and rapid cooling.

Reusing heat-treated milk
In this study, the researchers discuss that after cooling “flash-heat was successful in completely eliminating bacteria in the majority of samples, and prevented substantial growth for up to 8 h when stored at room temperature.”

To date, the safety of reheating previously heat-treated milk has not, to our knowledge, been studied. It should be noted that most literature speaks in terms of heating expressed milk for feeding but that mothers generally warm the (thawed) milk under running warm water or set it in a container in warm water for a short while to get the chill out of it. Gently warming should not be considered heat-treating. For optimal properties of breastmilk, reheating (warming) milk should not be done directly in a pan on the stove top nor in a container set in boiling water on the stove top (which would be heat-treating it unnecessarily).

Heat-treated milk can possibly be refrigerated or frozen following common food safety protocols. We suggest, however, that after a first feeding, milk that was heat-treated not be refrigerated and reheated again as anti-bacteriological properties can decline with increased handling.

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8. How do I feed the milk to my baby?

Always make sure that supplies are clean and wash your hands before handling breastmilk.

Babies have been fed milk by an at-the-breast tube system, by cup feeding, saucer, spoon, dropper, or by bottle.

The act of nourishing a baby at one’s breast (breastfeeding) is ideally not separated from the sustenance the baby is receiving (milk). Therefore, when a mother does not produce (enough) milk, an already latching baby would preferably get all additional breastmilk via an at-the-breast system.11

Expensive equipment is not required for this. It does not have to be an official at-the-breast system that you purchase/use. All that is needed is a long length of No. 5 French feeding tube (can be purchased or ordered at your local pharmacy), and some sort of container (like a bottle) to hold the breastmilk in. The following DIY version is perfectly adequate and keeps baby at his/her own mother’s breast, thus minimizing the risk of jeopardizing supply (as the breasts and supply of the woman are still being stimulated while baby is latched on and drinking).12

If this is not possible, and until breastfeeding and/or feeding with an at-the-breast system can be established, other methods are best used before giving a bottle, like using a cup. Avoiding bottle feeding is important in order to prevent nipple confusion if a mother hopes to fully breastfeed her baby eventually.13

On AskDr.Sears it is stated that “research has shown that not only is it possible for preemies to drink from a cup, but they also maintain a more stable blood-oxygen level during cup-feeding than during bottle-feeding.” The participant’s manual of the WHO’s Breastfeeding counselling (p.124) states:

“Why cup feeding is safer than bottle feeding:

  • Cups are easy to clean with soap and water, if boiling is not possible.
  • Cups are less likely than bottles to be carried around for a long time, giving bacteria time to breed.
  • A cup cannot be left beside a baby, for the baby to feed himself. The person who feeds a baby by cup has to hold the baby and look at him and give him some of the contact that he needs.
  • A cup does not interfere with suckling at the breast.

How to feed a baby by cup:

  • Hold the baby sitting upright or semi-upright on your lap.
  • Hold the small cup of milk to the baby’s lips.
  • Tip the cup so that the milk just reaches the baby’s lips.
  • The cup rests lightly on the baby’s lower lip, and the edges of the cup touch the outer part of the baby’s upper lip.
  • The baby becomes alert, and opens his mouth and eyes.
  • A LBW [Low Birth Weigh] baby starts to take the milk into his mouth with his tongue.
  • A full term or older baby sucks the milk, spilling some of it.
  • Do not pour the milk into the baby’s mouth. Just hold the cup to his lips and let him take it himself.
  • When the baby has had enough, he closes his mouth and will not take any more. If he has not taken the calculated amount, he may take more next time, or you may need to feed him more often.
  • Measure his intake over 24 hours –not just at each feed.14

Please see the AskDr.Sears website for other alternative feeding options (finger, spoon, saucer, dropper). Also see NBCI for more information on finger feeding.

If choosing to use a bottle, there are some very important things to consider:

  • Watch the baby. Babies will cue us when they are hungry. Hunger cues include (but are not limited to) rooting, chewing on their fists, and rapid eye movement as they are about to wake. Respond to baby’s hunger cues and not the clock.
  • Hold the baby in an upright, seated position. It is very important that baby not be fed from a bottle while lying on their back.Having a baby in a more upright position allows them to better control the flow of milk into their mouths.
  • Just as a breastfeeding mom would switch sides while nursing, switch baby from one arm to the other. It is important that baby has the opportunity to develop both eyes and both sides of their bodies.
  • Never push or force the bottle nipple into the baby’s mouth. Allow them to explore and draw the nipple in on their own.
  • Pace baby’s feeding. Even with a low-flow or slow-flow nipple (preferable for all babies), the milk can enter the baby’s mouth much quicker than they are able to take it in. If a nursing session would take 20 minutes, expect that a bottle feeding session would take the same amount of time.
  • Baby’s breastfeed with a certain suck and swallow rhythm. Often they suck 2 or more times before swallowing. We can mimic this by encouraging frequent pauses. Allow the baby to suck and swallow according to their rhythm and then tip baby forward a bit (to empty milk out of the bottle nipple) to simulate the pause. Tip them back slightly and allow the suck and swallow rhythm to happen again.
  • Watch the baby. By allowing them control over the feeding rhythm, we allow them to let us know when they are finished. Never force a baby to finish a bottle. Allow them to dictate when the feed is over.

It is critically important that babies and their care givers are able to engage together in a feeding. It is never safe to ‘prop’ a bottle for a feeding. It is not only unsafe, but contrary to our human nature.

For support and guidance with implementing any of these alternative feeding options, please find a professional lactation consultant or look in ‘Resources for support’ for referral suggestions.

Please see this section for information about handling and storing.

Next: How much expressed milk does my baby need?

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9. How much expressed milk does my baby need?

It is best to follow the baby’s lead. Volume needs change day-to-day and from baby to baby. Learning a baby’s unique communication style is an important part of the early bonding process.

According to ‘The participant’s guide of WHO’s Breastfeeding counselling’ (p. 127), the amount of milk to give is:

“Babies who weigh 2.5 kg or more:

  • 150 ml milk per kg body weight per day.
  • Divide the total into 8 feeds, and give 3-hourly.

Babies who weigh less than 2.5 kg (Low-birth-weight):

  • Start with 60 ml per kg body weight.
  • Increase the total volume by 20 ml per kg per day, until the baby is taking a total of 200 ml per kg per day.
  • Divide the total into 8-12 feeds, to feed every 2-3 hours.
  • Continue until the baby weighs 1,800 g or more, and is fully breastfeeding.

Check the baby’s 24-hour intake. The size of individual feeds may vary.”

This calculator can be used as a general guideline for babies that are receiving feeding from an at-the-breast system, a cup, or a bottle.

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10. Can donated breastmilk be reused?

With proper care and timely use, donated breastmilk can be reused as follows:

Fresh milk
Regarding raw and fresh milk, Lawrence writes: “Breastmilk can safely stand at room temperature for 6 to 8 hours and need not be discarded if the first feeding attempt is incomplete.”15

After feeding
Regarding reusing milk after a feeding, Dr. Ruth Lawrence writes: “Whether you can use the remaining milk really depends on how long it sits around. Once the baby takes the bottle, there is a certain amount of saliva that gets in the bottle that creates bacteria and gets saliva enzymes in the milk. This is why it isn’t good to give milk that has been sitting around. But, if it sits for only a half hour or so, this is fine.”16 There can be confusion as to what ‘sits around’ means. Eats on Feets assumes that in this context ‘sits around’ means ‘stand at room temperature.’

See ‘How do I feed the milk to my baby?’ for cleaner and thus safer feeding options.

After refrigeration
For raw and fresh (not frozen) breastmilk after refrigeration, this summary states: “[…] When infants do not finish a bottle of expressed breastmilk, doctors recommend unfinished portions be thrown away. This [small –ed.] study examined bacterial levels in expressed, partially consumed breastmilk that was stored for 48 hours at 4-6° C [bold –ed.]. A portion of unconsumed milk was examined as a control. Samples were taken every 12 hours for bacterial analysis. Tests were performed to identify total colony counts, pathogenic Staphylococci, coliforms and b-hemolytic Streptococci. This study showed no significant difference between bottles that were partially consumed and those that were not exposed to the baby’s mouth for 5 out of 6 participants. All milk samples had colony counts in the acceptable range of < 105 colony forming units per milliliter (CFU/ml). Although this project provides evidence that it may be safe to re-feed a child a bottle of breastmilk, due to the small sample size, further tests should be performed.”17

Most mothers reheat leftover and refrigerated milk. Dr. Ruth Lawrence writes: “If the milk is warmed up but not used, it is OK to reheat the milk once. But the more you reheat the more you decrease some of the valuable immunologic properties of the milk.”

After freezing
Regarding previously frozen raw milk, it is generally accepted that thawed milk can be kept in the refrigerator for up to 24 hours. According to the USDA, “Once food is thawed in the refrigerator, it is safe to refreeze it without cooking.” In this protocol, Dr. Anne Eglash,M.D. writes: “At this time, there is little information on refreezing of thawed [fresh –ed.] human milk. Bacterial growth and loss of antibacterial activity in thawed milk will vary depending on the technique of milk thawing, duration of the thaw, and the amount of bacteria in the milk at the time of expression. At this time no recommendations can be made on the refreezing of thawed human milk.”

Please see ‘How can breastmilk be thawed?’ for thawing instructions. Most mothers reheat (warm) previously frozen raw milk as well (after a first feeding). There is no research on whether this practice is safe or not.

Breastmilk that was frozen can be re-frozen after it has been heat-treated as well. This is the process that milk banks follow: frozen donated breastmilk is pasteurized, after which it is stored in the freezer.

Reusing heat-treated milk18

In this study, the researchers discuss that after cooling “flash-heat was successful in completely eliminating bacteria in the majority of samples, and prevented substantial growth for up to 8 h when stored at room temperature.”19

To date, the safety of reheating previously heat-treated milk has not, to our knowledge, been studied. It should be noted that most literature speaks in terms of heating expressed milk for feeding but that mothers generally warm the (thawed) milk under running warm water or set it in a container in warm water for a short while to get the chill out of it. Gently warming should not be considered heat-treating. For optimal properties of breastmilk, reheating (warming) milk should not be done directly in a pan on the stove top nor in a container in boiling water on the stove top (which would be heat-treating it unnecessarily). It is suggested however that after a first feeding, milk that was heat-treated not be refrigerated and reheated again.

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11. How do I clean or sterilize supplies and pump parts?

AskDr.Sears writes: “When you are pumping milk for a full-term, healthy baby, you do not need to worry about sterilizing storage containers or pump parts. Wash your storage containers in hot soapy water, and wash your hands thoroughly with soap and water before you pump. Check the manufacturer’s instructions for information on washing parts of the pump. Storage containers and parts of some pumps can be washed in a dishwasher.

Mothers who are pumping milk for a sick or hospitalized baby will need to be more careful about milk handling and sterilization procedures.”

From Food Smart: Safe feeding for infants: “To reduce the risk of contamination, all bottles and feeding equipment must be sterilized until your baby is three months old. Equipment can be sterilized with boiling water, with sterilizing solution, or with a steam-sterilizing unit. Please note that a dishwasher does not sterilize bottles or feeding equipment [It sanitizes. –ed.]. After three months of age it is sufficient to wash bottles and feeding equipment with hot soapy water and then rinse.”

We encourage recipients to discuss their and their baby’s needs with potential donors.

The above website proceeds to explain the steps involved in cleaning and sterilizing:

“To clean:

  • Always thoroughly wash and dry your hands with soap and water before cleaning and sterilizing bottles and feeding equipment.
  • Make sure the area used to clean and sterilize your baby’s bottle and feeding equipment is clean.
  • Wash bottles and feeding equipment thoroughly in hot soapy water. If using feeding bottles, use clean bottle and teat brushes to scrub the inside and outside of the bottles and teats to ensure all remaining feed is removed.
  • Rinse the bottles and feeding equipment well in hot water and air dry it, or wash it in a dishwasher.

To sterilise by boiling:

  • Place the bottles, feeding equipment and preparation utensils in a pot if you use glass bottles, a clean cloth in the bottom of the pot may stop bottles from chipping.
  • Fill the pot with water, high enough to cover everything.
  • Bring the water to boil and boil for five minutes, turn off element, and keep pot covered until feeding equipment is needed.
  • Use clean tongs to lift the bottles out and place them on a clean dry surface.
  • If equipment is not used immediately cover and store in a clean place. Store bottles with the teat upside-down in the bottle, or cover the teat with the sterile cap.

For other methods of sterilisation follow the manufacturer’s instructions carefully. These methods include:

  • Chemical sterilization using sterilizing solution in a plastic container.
  • Microwave sterilization using a special microwave steam-sterilizing unit. This is not suitable for glass bottles.
  • Steam sterilization.”

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When using #5 French feeding tubes for at-the-breast feeding or finger feeding, rinse the tubes with hot, soapy water and use a syringe to force soapy water through the tubes, followed by clear water after each feeding. Dry the tubes by pushing air through the tubes.

The longevity of these tubes is not known. The tubes should be replaced when they become gummy, discolored, brittle, etcetera.

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12. How do I protect my breastmilk during a power outage?

Community-based breastmilk sharing can be vital in times of emergency. Identifying local breastmilk resources, whether through family-to-family donation or via wet-nursing, can help provide breastmilk to the most vulnerable in a time of need.

For stored breastmilk, please follow these guidelines or these guidelines in case of a power outage or other emergency.

Stay warm and be safe!

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  1. In ‘Nursing: The 3 M’s of Breast-feeding the Preterm Infant’: “Studies measuring these factors [size, need to recycle, ease of cleaning/sterilizing, protection of nutrients, considerations regarding bacteria, and ability to connect directly to the pump flange] conclude that glass and hard clear plastic (polypropylene) are the recommended choices for milk collection/storage. Plastic bags are a poor choice for milk storage […] owing to their non-sterile condition, greater loss of fat (adherence to sides of bag), and difficulty in handling.” Plastic bags can however be more convenient. Plastic bags specially designed for freezing expressed human milk are available from many companies that specialize in products for breastfeeding mothers and babies. []
  2. However, the CDC states: “Do not add fresh milk to already frozen milk within a storage container. It is best not to mix the two.” []
  3. “Breastmilk can safely stand at room temperature for 6 to 8 hours and need not be discarded if the first feeding attempt is incomplete. In contrast, formula must be refrigerated and discarded after the first feeding attempt because it contains no antibodies or infection protection factors”. Lawrence, Ruth. Breastfeeding, A Guide for the Medical Profession. P. 438. Print. []
  4. According to the ABM: “Very few studies have evaluated milk storage safety at 158C (598F), which would be equivalent to a blue-ice pack in a small cooler. Hamosh et al. suggested that human milk is safe at 158C for 24 hours, based on minimal bacterial growth noted in the samples from their study.” []
  5. USDA freezing information []
  6. Please note that the information from the Transportation Security Administration (TSA) on this website is outdated. For current information see ‘Travel By air.’ []
  7. 100 ounces of milk weighs about 13 pounds (0.13 pounds per ounce, based on the weight of a gallon of cow’s milk). This is an assumed estimate, and will allow you to roughly estimate shipping costs. In addition to the weight of the milk, you will have to account for the weight of the dry ice or frozen packs used to keep the milk frozen and the weight of the container. []
  8. http://www.dryiceinfo.com/shipping.htm []
  9. Please see ‘Human Immunodeficiency Virus (HIV)’ and ‘HIV and the global context of infant feeding’ for more information. []
  10. See: -‘Heat Treatment of Expressed Breast Milk Is a Feasible Option for Feeding HIV-Exposed, Uninfected Children after 6 Months of Age in Rural Zimbabwe’

    -‘Flash-Heat Inactivation of HIV-1 in Human Milk’

    -‘Inactivation of Cell-Associated and Cell-Free HIV-1 by Flash-Heat Treatment of Breast Milk’ []

  11. Please know that the company that manufactures one of the at-the-breast systems is not WHO code compliant. More information on the ‘International Code of Marketing of Breast-milk Substitutes’ here. []
  12. Other important benefits of breastfeeding include proper jaw and facial development which reduces both ear infections and bite issues, by preventing malocclusion. The skin to skin contact that breastfeeding provides helps babies acquire the beneficial bacteria that protects them from diseases and builds their immune system. Skin to skin also provides relaxation for both mother and child due to the effects of oxytocin. Long term benefits are laid out in this WHO publication. Please see ‘Why breastmilk?’ for references. []
  13. From AAP’s Promoting and Supporting Breast-Feeding: “Nipple confusion occurs when a baby has not had the opportunity to establish the correct mouth movements for proper breast-feeding. Early and subsequent use of pacifiers, water, glucose water and formula supplementation have been shown to promote early weaning and nipple confusion. The frequent use of an artificial nipple early in life has been shown to promote a less effective mouth movement; this was demonstrated with ultrasonography over a decade ago. For this reason, the physician should encourage the staff and the patient to address breast-feeding problems first, with direct observation of breast-feeding, before considering the use of supplementation.” []
  14. See ‘How much expressed milk does my baby need?’ []
  15. Lawrence, Ruth. Breastfeeding, A Guide for the Medical Profession. P. 438. 2005. Print. []
  16. Using alternative feeding options to a bottle and/or using small amounts at a time avoids waste and contamination. []
  17. Brusseau, R. “Bacterial Analysis of Refrigerated Human Milk Following Infant Feeding.” May 1998. Web. []
  18. This can be the case if a donor heat-treats the milk because of high lipase or after a recipient heat-treats the milk and there is milk left over after a feeding for instance. []
  19. Per the same study “Flash-heated and unheated samples were stored at 2–8oC [35oF–46oF –ed.] overnight to be processed for microbiology assays the next morning, 18–24 h after collection. At this time, both flash-heated and unheated aliquots were placed at room temperature (23C) [73oF –ed.] and allowed to stand, in capped vials, for up to 8 h.” []

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