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PURPOSE
The purpose of this practice support document and related appendices is to describe the safe handling,
storage, administration and transport of expressed breast milk (EBM).
POLICY STATEMENTS
Staff or family label, store, retrieve, administer EBM in designated bottles, bins, refrigeraters and freezers
on each unit. On occasion families ship milk to or from the hospital.
SITE APPLICABILITY
Safe handling, storage, administration and shipping of expressed breast milk occurs in the Antepartum,
Postpartum, Birthing, Ambulatory areas, and Neonatal Program including the NICU in the Acute Perinatal
Program at BC Women’s Hospital and all inpatient and critical care areas at BC Children’s Hospital.
PROCEDURE
1.1 Preparation: Registered Nurse (RN)
Identify each mother expressing human milk
Provide information to the mother/family referring to the Teaching Flowsheet - Appendix A.
Use education materials available – see Teaching Aids.
1.2 Labelling
Request the Unit Clerk prepare and print multiple, computer generated waterproof labels designated for
EBM. In the NICU this will involve both small and large labels.
Verify the information on the label is correct.
Ask the mother to verify the labels are correct.
Give mother the labels and ask her to label her own EBM bottles when possible.
The pre-printed label includes the:
Printed mother’s (on postpartum) or infant’s full name (in NICU and BCCH units)
Identification/unit number
Blank for date and time of expression
Blank for date and time when fully thawed
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BCCH Child & Youth Health Policy and Procedure Manual Page 1 of 5
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EXPRESSED BREAST MILK (EBM): SAFE HANDLING,
STORAGE, ADMINISTRATION AND TRANSPORT
1.4 Equipment
Storage of EBM
Refrigerators and Freezers for Milk Storage
Label appropriately for storage of human milk
Plug into emergency power circuits so that power outages will not result in loss of milk
Keep a thermometer in each unit
Temperature is monitored by a designated person every 24 hours and a written record of the
temperatures is maintained.
Adjust doors to facilitate automatic closing as per manufacturer’s instructions.
Clean all fridge and freezers on a regular monthly basis by defrosting and washing as
appropriate.
Instruct all staff and families to check bottle label with one other person to confirm correct milk is
being removed for the correct baby.
Spills of milk are cleaned up promptly and the area sanitized.
Refrigeration of EBM
Fresh EBM is safe at room temperature for 6 hours. Refer to the pamphlet “Cleaning Equipment and the
Storage and Transport of Mother’s Milk” – See the table on page 3.
Refrigerate EBM as soon as possible after expression if not being used.
Place EBM in the interior of the designated EBM refrigerator.
Do not store EBM in the door of the refrigerator or freezer. The temperature is more stable in the
interior of the refrigerator or freezer.
Fresh EBM can be stored in the refrigerator for 72 hours.
Freezing of EBM
In hospital, freeze any EBM that will not be used within 72 hours.
Freeze EBM in a refrigerator that has a separate door for the freezer, use within six months or
Freeze in a deep freezer with a temperature of -20º Celsius, use within twelve months.
Do not freeze EBM with additives.
Do not refreeze thawed EBM.
Discard any EBM not used by the expiry date.
Storage Bins
Store labelled EBM bottles in the designated covered EBM bins.
Label each bin with infant’s name and ID number. Some infants may have more than one bin.
Flag a bin with a name alert sticker for same or similar surnames.
Check the storage area and ensure adequate space and appropriate organization for all stored EBM.
Consider the storage limits on each unit.
Provide information to family if volume of EBM exceeds unit limits and assist the family to remove the
excess EBM, see 1.7.
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EXPRESSED BREAST MILK (EBM): SAFE HANDLING,
STORAGE, ADMINISTRATION AND TRANSPORT
DOUBLE check the correct infant is receiving the correct breast milk.
At the bedside double check the infant name and ID number on the EBM label:
With the infant ID bracelet AND
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EXPRESSED BREAST MILK (EBM): SAFE HANDLING,
STORAGE, ADMINISTRATION AND TRANSPORT
Error Information
When an infant receives another mother’s milk see:
Appendix E Incorrect Administration of EBM
Appendix F When Your Baby has Received Another Mother’s Milk - Error Information for Families
DOCUMENTATION
DOCUMENT EBM feeds using the following documentation tools:
BCCH – Flow sheet
EBM labels
Intake and Output Record – Document volume of EBM fed to infant
Interprofessional Progress Notes (BCW) or Nurses Notes (BCCH)
NICU Flow Sheet
REFERENCES
Barry, C and Lennox, K. (1998). Management of expressed breast milk. Is the right milk being fed to
infants? Canadian Journal of Infection Control. Spring,16-9.
Cleaning Equipment and the Storage and Transport of Mother’s Milk (2011). CW#501, BC Women’s.
Human Milk Banking Association of North America (HMBANA) www.hmbana.org.
Jocson, M.L., Mason, E.O. Schanler, R. (1997). The effects of nutrient fortification and varying storage
conditions on host defence properties of human milk. Pediatrics, 10(2):240-243.
Jones, F. (2011). Best practices for the expressing, storing, and handling mother’s milk in hospital, in day
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EXPRESSED BREAST MILK (EBM): SAFE HANDLING,
STORAGE, ADMINISTRATION AND TRANSPORT
APPENDIX
Appendix A Safe Handling, Storage and Administration of EBM Patient Teaching Checklist
Appendix B Assembling Breast Pump Kits For Expressed Breast Milk and Cleaning
Appendix C Expressed Breast Milk (EBM) Handling, Storage and Administration Process
Appendix D Breast Milk Expression Using Electric Pump
Appendix E Incorrect Administration of Expressed Breast Milk
Appendix F Parent Letter-When Your Baby Has Received Another Mother’s Milk
Appendix G Transport/Shipping of Mother’s Milk
Appendix H Unclaimed EBM in Freezer
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