Tasmanian Health Organisation - North

WOMENS & CHILDRENS SERVICES, LAUNCESTON GENERAL HOSPITAL SDMS Id No.: P2010/0298-001 WACS Policy No: 7.6-12

Donor Human Milk Use

Document Number Effective From Functional Sub Group Summary Policy ID (To be assigned by Strategic and Portfolio Services)W ACS Policy 7.6-2012 June 2012 Lactation Services, LGH This policy is designed to govern education, donor screening and milk testing that needs to be completed before another mothers breastmilk can be given to an infant within the LGHs care. Donor Breastmilk and Wet Nursing: LGH Policy 7.6-08WACS Womens and Childrens Services, LGH Dianne Haworth & Jill Hanson, Lactation Consultants WACS medical, midwifery and nursing staff LGH areas caring for breastfed babies Refer to Breastfeeding Policy and Guidelines for further information Policy Type Review Date
Prepared by Through Through

Replaces Doc. No. Author Area Contact Applies to

Departmental June 2015

Lactation Consultants, LGH Co-Director, Nursing & Midwifery, WACS Co-Director, Medical, WACS 6348 8934 6348 8976 6348 8972 31 May 2012 21 August 2012 21 August 2012

D Haworth & J Hanson Sue McBeath Amanda Dennis

Introduction/Purpose
If a mother is unable or unsure if she will be able to provide adequate quantities of her own breastmilk, she may request the use of known donor human milk as a supplement. This policy is designed to govern education, donor screening and milk testing that needs to be completed before a known donors breastmilk can be given to an infant within the LGHs care.

Policy Statement
This Policy may be varied, withdrawn or replaced at any time. Compliance with this directive is mandatory for the Department of Health and Human Services. PLEASE DESTROY PRINTED COPIES. The electronic version of this Policy is the approved and current version and is located on the Agencys intranet. Any printed version is uncontrolled and therefore not current. Page 1 of 9

In some cultures it is common practice to breastfeed a relative or friends baby when the mother is not able. Mothers need to be aware of the potential for transmission of infectious pathogens via this practice. Donor Human Milk (DHM) Banks reduce the risk of viral and bacterial transmission by judicious screening of donors and pasteurisation of donated human milk. The LGH does not have a DHM bank; or access to donor milk; or a milk pasteuriser. For parents requesting the use of a known donors breastmilk for their infant, the screening and testing must be completed before that breastmilk can be used. There will be no explicit advertising or promotion of this policy, staff will be made aware of the policy and the pathway for referral to be utilised when a parental enquiry is received.

Key Definitions
DHM refers to Donor Human Milk, the breastmilk supplied for the purpose of feeding another mothers infant with the consent and understanding of all parents. Recipient parent(s) are the Parents of the baby anticipated to receive the DHM. A Known Donor is a friend or family member of the recipient parents. They intend to provide breastmilk for the (recipient) baby in the event that the recipients mother cant supply sufficient breastmilk for the infants needs; this donation must not compromise the health or nutritional intake of the Known donors own breastfed baby. National Institute for Health and Clinical Excellence (2010) criteria for safe unpasteurised human milk is less than104 CFU/ml E Coli or 104 CFU/ml S Aureus or 105 CFU/ml total microorganisms.

Principles
Provision of human milk is a birth right of all babies. Parental infant feeding choices should be informed, respected and supported. Parents have a right to explore options reasonably available to provide optimal care and nutrition to their infant. There are risks associated with giving another mothers breastmilk to a baby, the transmission of viruses and bacteria can occur via breastmilk. Donors must be screened before they can provide DHM to a baby within the LGH. Confidentiality of donor screening outcomes must be upheld and ensured at all times.

Implementation/Policy in Operation
A flow chart of the steps to implementation is attached (attachment 1)
This Policy may be varied, withdrawn or replaced at any time. Compliance with this directive is mandatory for the Department of Health and Human Services. PLEASE DESTROY PRINTED COPIES. The electronic version of this Policy is the approved and current version and is located on the Agencys intranet. Any printed version is uncontrolled and therefore not current. Page 2 of 9

Referral: Parents enquiring about the ability to provide DHM to their infant
should be referred to the Lactation Service for further discussion and coordination. Referral to WACS Medical Co-Director as soon as possible for completion of 1) recipient parent consent and liability waiver (attachment 2) and 2) known donor eligibility assessment (attachment 3) - ensuring time to test and process the DHM prior to the anticipated birth or admission of the infant.

Providing Information: Referring practitioner or Lactation Consultant (LC)

will discuss expected process and provide information for parents and donor.

Donor Screening: completed by WACS Medical Co-Director

Donor will complete health questionnaire (attachment 3). Known donor consent for use of DHM by recipients infant to be signed (attachment 4). Pre test counselling conducted as required. Donor blood to be tested for: HIV (anti HIV 1, anti HIV 2); HTLV (anti HTLV I, anti HTLV II); Hep B (anti HBc, HbsAg); Hep C (anti HVC) Syphilis (TPHA or TPPA) and CMV (anti CMV). NB results for HTLV can take a working week to obtain eg Mon Fri or Thurs Wed. If any blood tests positive: post test counselling conducted and recommendations for follow up arranged, donor ineligible to provide DHM. If all blood tests negative: post test counselling conducted and appointment with LC made. Recipient parent to be notified of eligibility of donor based on completed screening process only, donor confidentiality to be ensured, no details will be released.

Donor Human Milk Processing: coordinated by LC

LC to discuss and provide information to the known donor regarding safe collecting, storing, labelling and transporting of DHM. Organise expressing opportunities at LGH if possible or for milk to be transported fresh and in appropriate cold storage from donors home on day of expressing to minimise contamination by bacteria or other pathogens. DHM sample per bottle or bag taken for microbiological testing, ensure specific DHM labelling and all bottles/bags recorded on a Freezer storage register. Freeze DHM. All DHM that meets NICE criteria for safe unpasteurised human milk (see Definitions) to be stored frozen until needed, document microbiology result on label. Any DHM not meeting criteria to be discarded. Defrost as required by recipient infant. Follow LGH protocol (Breastmilk (EBM): Safe Handling Policy) re storage and use of human milk.

This Policy may be varied, withdrawn or replaced at any time. Compliance with this directive is mandatory for the Department of Health and Human Services. PLEASE DESTROY PRINTED COPIES. The electronic version of this Policy is the approved and current version and is located on the Agencys intranet. Any printed version is uncontrolled and therefore not current. Page 3 of 9

Rationale/Evidence Base
Allen, J & Hector, D 2005, Benefits of breastfeeding, NSW Public Health Bulletin, vol16, no3,pp 42-46. Hartmann, B, Pang, W, Keil, A, Hartmann, P & Simmer, K 2007, Best practice guidelines for the operation of a donor human milk bank in an Australian NICU, Early Human Development, vol 83, pp 667-673. NICE: National Institute for Health and Clinical Excellence 2010a, Understanding NICE guidance: Information for people who use NHS services Collecting and storing donor breast milk in milk banks, http://www.nice.org.uk/nicemedia/live/12811/47494/47494.pdf NICE: National Institute for Health and Clinical Excellence 2010b, Donor breast milk banks: the operation of donor breast milk bank services http://guidance.nice.org.uk/CG93/QuickRefGuide/pdf/English

Outcomes
The decision by parents to provide Known Donor Human Milk to their infant is a well informed one. DHM is used supplementally and does not impinge on the nutritional needs of the donors baby. The DHM provided to infants at LGH is free from viral or bacterial contamination. The DHM is able to be tracked from known donor to recipient infant. WACS staff enable parents to provide exclusive breastmilk to their infant if that is their request.

Responsibilities/Delegations
WACS Medical Co-Director or delegated practitioner will inform parents of their options, obtain written consent for use of donor human milk for their infant and a liability waiver for LGH staff, and arrange donor screening appointment and refer on to Lactation Service for liaison and follow up. Lactation Consultants will follow up information provision and ensure donor and DHM screening completed in timely manner to ensure DHM available prior to birth or admission of recipient infant. WACS medical and nursing staff will be familiar with this policy and support parents and donor to facilitate the recipient parents request for the use of DHM for their infant.

Audit and Compliance

Human Milk tracking and tracing procedures will be strictly adhered to and labelling specific to DHM will be used on all DHM bottles. An audit specific to DHM will be conducted following each admission of an infant using DHM and results kept in the DHM folder
This Policy may be varied, withdrawn or replaced at any time. Compliance with this directive is mandatory for the Department of Health and Human Services. PLEASE DESTROY PRINTED COPIES. The electronic version of this Policy is the approved and current version and is located on the Agencys intranet. Any printed version is uncontrolled and therefore not current. Page 4 of 9

Maternal UR Baby UR Donor UR

Name Name Name Example of DHM container label

DHM expressed: date Time DHM samples sent: date Time DHM cleared for use: date DHM thawed: date Time A folder specific to DHM will be kept in the Lactation Office with policy, documents, information for recipient parents and donors, pathology forms and DHM labels ready to be used as needed. Failure to comply with this policy, without providing a good reason for doing so, may lead to disciplinary action.

Attachments
1 2 3 4 Process Flow Chart Recipient Parent: Consent & Liability Waiver Donor health questionnaire Donor consent for DHM to be used by recipient baby

Attachment 1 Donor Human Milk Policy - WACS Policy 7.6

Process Flow chart for Donor Human Milk (DHM) Use at LGH Expectant parents considering use of DHM identified 1 Referral to Lactation Service for coordination of process 2 Referral to WACS Co-Director of recipient parents and donor Recipient parent to sign consent and liability waiver 3 Donor to complete consent, health questionnaire and blood tests: anti HIV 1 and anti HIV 2, anti HTLV I and anti 4 HTLV II, HbsAg, anti-HBc, anti HCV,TPHA or TPPA, anti CMV 5

Week One

This Policy may be varied, withdrawn or replaced at any time. Compliance with this directive is mandatory for the Department of Health and Human Services. PLEASE DESTROY PRINTED COPIES. The electronic version of this Policy is the approved and current version and is located on the Agencys intranet. Any printed version is uncontrolled and therefore not current. Page 5 of 9

Blood Tests negative Donor appt with LC 6 Info re safe collecting, storing and 7 transporting of human milk Provide donor with storage bottles 8 Donor expresses at LGH or deliver DHM to LC 9 Ensure correct labelling & registration DHM sample sent to pathology 10 Freeze DHM until required 11 12

Blood tests positive Donor not eligible Arrange post test counselling Inform recipient parent of donor ineligibility (no details)

Week Two

Milk bacteria count acceptable level acceptable level Store frozen DHM 13 Recipient baby born/ needs DHM Follow protocol re dispensing of EBM 14 Use defrosted DHM within 24 hours 15

Milk bacteria count above

Donor notified Re-educate re hygiene Discard milk, record on register Week Three

This flowchart is based on LGH Policy WACS Policy 7.6 Donor Human Milk Use. See policy for references and further information

Attachment 2

Donor Human Milk Policy - WACS Policy 7.6

Tasmanian Health Organisation North

LAUNCESTON GENERAL HOSPITAL

Use of Donor Human Milk Consent and Waiver:

Recipient Parents

This Policy may be varied, withdrawn or replaced at any time. Compliance with this directive is mandatory for the Department of Health and Human Services. PLEASE DESTROY PRINTED COPIES. The electronic version of this Policy is the approved and current version and is located on the Agencys intranet. Any printed version is uncontrolled and therefore not current. Page 6 of 9

I________________________________ (name of parent) request and consent to my baby_________________________ (name of baby) receiving donor human milk from _________________________ (name of donor) following completion of donor screening and milk testing as has been explained to me by Launceston General Hospital staff. The benefits and risks of my baby receiving unpasteurised donor human milk have been explained to me. I release the Launceston General Hospital and its staff from any liability in assisting me with this request.

Signature of parent _______________________Date______________

Signature of doctor _______________________Date _____________

Attachment 3 Donor Human Milk Use Policy - WACS Policy 7.6

Tasmanian Health Organisation North

LAUNCESTON GENERAL HOSPITAL

Donor Health Questionnaire

The decision to donate breastmilk to the infant known to you must be yours alone. A decision made freely and willingly. Your health and well being and that of your own infant are important when donating your breastmilk to another mothers infant.
This Policy may be varied, withdrawn or replaced at any time. Compliance with this directive is mandatory for the Department of Health and Human Services. PLEASE DESTROY PRINTED COPIES. The electronic version of this Policy is the approved and current version and is located on the Agencys intranet. Any printed version is uncontrolled and therefore not current. Page 7 of 9

Please answer truthfully, these questions and blood tests to follow will determine your eligibility to donate breastmilk. All results are strictly confidential. This questionnaire will be discussed with you by a health professional prior to conducting blood tests for viral illnesses that can be passed on via breastmilk. Depending on answers, your GP may be contacted to clarify or gain more information regarding any illnesses, tests or medication that may be affecting your health or suitability of your breast milk to be donated. Your full name: ..................................................... Your date of birth:....../......../......... Your babys name: ................................................. Babys date of birth:......./......./.......... Your GPs name: ........................................ GP practice: ...........................................

In the last 12 months: (tick Yes or No, provide details if required) Have you been in good health? Has your baby been in good health? Have you had any tests/xrays/treatments? Eligible Details: ............................................................................................................................ ............... Have you had recent exposure to infection? Eligible Details: ............................................................................................................................ ................. Are you a smoker? Yes No Yes Eligible No Yes No Yes Yes Yes No No No Eligible Eligible

Are you taking any prescription or non prescription medication?

If Yes, details? ................................................................................... Eligible Are you taking any herbal or vitamin/ mineral supplements? Yes No

If Yes, details? ................................................................................... Eligible Do you consume more than two glasses of alcohol per day? Eligible Yes No

This Policy may be varied, withdrawn or replaced at any time. Compliance with this directive is mandatory for the Department of Health and Human Services. PLEASE DESTROY PRINTED COPIES. The electronic version of this Policy is the approved and current version and is located on the Agencys intranet. Any printed version is uncontrolled and therefore not current. Page 8 of 9

Do you consume more than three caffeine drinks per day? Yes Eligible

No

Thank you, the answers will be checked and discussed with you before blood tests are done. Attachment 4 Donor Human Milk Use Policy - WACS Policy 7.6

Tasmanian Health Organisation North

LAUNCESTON GENERAL HOSPITAL

Use of Donor Human Milk Consent and Waiver:

Donor

I________________________________ (name of donor) request and consent to baby__________________________ (name of baby) of _________________________________ (name of parents) receiving my breast milk following completion of the screening process and milk testing as has been explained to me by LGH staff. I consent to blood testing for the purpose of assessing my eligibility to be a human milk donor. I acknowledge that I will receive no benefit or payment for this donation, and that the health and wellbeing of my own infant is not being compromised. I release the Launceston General Hospital and its staff from any liability in assisting me with this request.

Signature of donor ________________________Date______________

Signature of doctor _______________________Date _____________

This Policy may be varied, withdrawn or replaced at any time. Compliance with this directive is mandatory for the Department of Health and Human Services. PLEASE DESTROY PRINTED COPIES. The electronic version of this Policy is the approved and current version and is located on the Agencys intranet. Any printed version is uncontrolled and therefore not current. Page 9 of 9