Breastmilk storage and handling

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Breast milk is recommended by numerous health authorities across the world, including the World Health Organization, UNICEF, and the American Academy of Pediatrics, as the optimal exclusive source of nutrition for infants from birth up to six months. Expressing and storing breast milk allows parents to sustain breastfeeding for a longer period of time. However, different storage practices may alter the composition of breast milk, such as variations in fat content, antioxidants, lactoferrin, and immune components. Further, improper handling and storage may increase bacterial growth in breast milk which makes it unsafe for consumption.

Contents

Breastfeeding

Recommendations and benefits

The World Health Organization (WHO), UNICEF, and the American Academy of Pediatrics (AAP) recommend exclusive breastfeeding for infants up to 6 months, and continuing to breastfeed along with the introduction of safe complementary foods for up to 2 years or beyond, as desired by parent and child. [1] [2]

Breastfeeding initiation, and length of exclusivity, are associated with health benefits for infants, including lower risks of Sudden Infant Death Syndrome (SIDS), infant and neonatal mortality, infections, asthma, obesity, and diabetes. [2] Breastfeeding parents can also experience lower rates of diabetes, high blood pressure, and breast, ovarian, and endometrial cancers. [2]

Breastfeeding approaches

Traditionally, breastfeeding has been defined as the consumption of breastmilk by any means, be it directly at the breast, or feeding expressed breast milk. [3] When direct feeding at the breast is not possible, expressed breast milk retains many unique nutritional and immunological qualities, and as such remains the gold standard for feeding infants. [4] The practice of feeding infants expressed milk is common in NICU (Neonatal Intensive Care Unit) settings, where it is challenging for parents to breastfeed, but it has also expanded to other contexts and situations which allow parents to be able to offer breastmilk for more sustained periods, especially given the increased prevalence of commercial manual and electric breast pumps. [5] [6] In the United States about 85% of birthing parents express milk at some point during the first four months of the infant's life. [7] Estimates of parents who exclusively express breast milk range from 5% of breastfeeding parents in the United States, to 18% in Singapore. [6] Parents report a broad range of factors that contribute to their desire to express breast milk, including experiencing difficulties with latch, embarrassment of breastfeeding in public, the desire to have other caregivers help with feeding, return to paid work, concerns about over or under supply, and body weight considerations. [8]

In some situations, the ability to express breast milk is linked to longer duration of breastfeeding. [9] To ensure the safety and continued benefits of expressed breastmilk, proper handling and storage of breastmilk are essential. [5] [6] [10] [11]

Breast milk expression

Cleaning procedures for handling breast milk

Hand washing with antibacterial soap is recommended before expressing and handling breast milk. [5] [12] [4] If soap and water are not available, the best way to safely clean hands is through the use of an alcohol-based hand sanitizer that contains more than 60% alcohol. [12] When expressed breast milk contains fewer bacteria at the time of expression, this leads to less bacterial growth during storage. [4] A study examined the impact of washing breasts with antibacterial soap prior to pumping, and while it did reduce the number of bacteria, it is not routinely recommended due to logistical considerations and concerns about soap residue in the expressed breast milk. [5]

Breast pump parts in microwave sterilizer Hands Free Breast Pump.jpg
Breast pump parts in microwave sterilizer

Some studies have examined outcomes related to cleaning and disinfecting equipment used for expressing. One study found that educating parents on how to clean equipment reduced presence of bacteria, and that the main sources of contamination were containers for storage and the pump parts. However, none of the studies included in the systematic review examined the long-term impact of reduction of contamination at collection. [5] Some studies have found an association between the levels of protein content and bacterial growth, with higher levels of protein present in expressed milk that has lower levels of bacterial growth. [4]

In the United States the FDA (Food and Drug Administration) recommends that all equipment that comes into contact with breast milk should be cleaned after each use. [13] To properly clean breast pump parts, each piece that came into contact with breast milk should be rinsed with cool water as soon was possible after pumping. Afterwards, each piece should be washed separately with dish soap and warm water, and then rinsed with hot water 10-15 seconds. Drying pump parts with cloth towels should be avoided because they can transmit bacteria - instead, pump parts should be placed on a paper towel or clean drying rack and allowed to air dry. [4] Some breast pumps can be placed the top rack of the dishwasher. [13] Although microwave sterilizers are commercially available, they do not meet the FDA definition for sterilization. Nonetheless, they are considered adequate for cleaning pump parts when used by a single user. [13]

Breast milk expression methods

Breast milk can be done by hand expression, or through the use of a breast pump. [4] While both approaches to breast milk expression are effective, some studies have found that breast pumps are more efficient (higher volume extracted per unit of time). [7] With proper hand washing techniques and cleaning of breast pump parts, there is no difference in expressed breast milk contamination through manual or pump expression. [4] Further, there is no evidence to support discarding the first few drops of expressed breast milk to reduce the risk of bacterial contamination. [4]

Recommendations for the approach to breast milk expression depends on individual circumstances, thus recommendations by health care providers should be tailored to each parent-infant dyad. [7]

Hand expression

Hand expression is a technique that removed breast milk through the compression of milk ducts. [7] The CDC (Centers for Disease Control and Prevention) recommends that all lactating people learn how to express breast milk by hand as it can be helpful in emergency situations where there is no access to a breast pump, no electricity to operate a breast pump, or in cases of unexpected separation from infant. [14] Hand expression can also help relieve engorgement, as well as stimulating milk production when parents want to increase their supply of breast milk. [15]

Breast pumps

Breast pumps remove breast milk through suction instead of compression. [7] There are three main types of breast pumps: manual, battery-powered, and electric. [16] Manual pumps require a handle or lever be squeezed by the user which creates a vacuum that extracts the breast milk. Battery-powered and electric pumps rely on a small motorized pump which creates suction to collect milk. [16] Electric pumps can also be separated into mini-electric, double electric, and hospital grade electric. [7]

Breastmilk storage

Impact of storage on breast milk

Breast milk frozen and labeled in storage bags Frozen Breast milk.jpg
Breast milk frozen and labeled in storage bags

Storing milk in a refrigerator or freezer has been found to have an impact on different aspects of breast milk, including bacterial contamination, immunological components, and the nutritional quality. [5] [10] Most studies have found that the number of bacteria stays constant from the time of collection when stored at 4 to 6.8°C for 24 to 96 hours, and the number of bacteria tends to decrease considerably (or stay stable) when stored at temperatures of -20°C for up to 6 weeks. [5] Further, when refrigerating instead of freezing, pyrex bottles preserved expressed breast milk's bactericidal activity better. [5]

When comparing refrigerated and frozen expressed breast milk, breast milk refrigerated at 4 to 8°C seems to maintain concentrations of lactoferrin comparable to fresh breast milk, while frozen milk at -20°C has documented decreases in lactoferrin, and immunological components such as peroxidase, immunoglobulin A, and lysosomes. [5]

In terms of nutritional components, antioxidants and fat content are not significantly impacted by storage at 6.8°C for 96 hours [5] or at -20°C for (non-specified) short durations [10] . However, storing milk at -80°C has been demonstrated to decrease antioxidant activity and fat content considerably and is not recommended for longer than 1-2 months. [5] [10] One systematic review found that the total fat content of expressed breast milk did not vary by more than 10% through most storage practices, and the authors considered that most of this loss was likely to have been through adherence of fat to container surfaces. [17] Further, the proportion of triglycerides to free fatty acids in the expressed breastmilk also vary, which is likely to enzymatic activity. The loss of fat content is important to take into consideration when calculating caloric density and energy intake for preterm and/or low-birth weight infants, and may be addressed by adding milk fortifiers to expressed breast milk. [17]

The enzyme that breaks down fats in breast milk is called lipase, and this process can cause a soapy smell or taste in thawed milk. [4] La Leche League recommends scalding as a way to deactivate the enzyme, and states that scalded milk is still a healthier choice than commercial infant formula. [11] Scalding milk consists of heating the expressed milk until there are bubbles around the edges of the container (but not boiling) and then cooling quickly and freezing.

Recommendations for breast milk storage

Breast milk should be stored in special milk storage bags, or clean containers designed for breast milk storage, and clearly labeled with the date it was expressed. [12] Containers and bags that are not intended for storing breast milk should be avoided. When bottles have the recycling symbol number 3 or 7 this indicates that the container may have BPA, thus these should be avoided for breast milk storage. [12] [11] Polypropylene plastics (recycling symbol 5) are safer, as are glass containers. [11]

Many different health entities and organizations recommend different ranges for optimal temperatures and time spans for storing breastmilk. The table below provides acceptable ranges from a variety of sources included in different systematic reviews and health authority guidelines, which are recommendations provided for families with healthy, full-term babies. [5] [6] [10] [12] [11] [4] While there is variability on the recommendations for temperature and duration of storage, there is agreement across all sources that thawed milk should never be re-frozen. [6]

Storage LocationTemperatureDurationNotes
Room temperature26°C (78.8°F) or lower6-8 hours3-4 hours is optimal at 16-29°C and 6-8 hours only when the breast milk was collected under "very clean" conditions.

Ideally, expressed breast milk should be transferred to a refrigerator or frozen as soon as possible.

Refrigerator5°C (41°F) or lower72-96 hours (3-4 days)At 4°C and under "very clean" conditions, this can be extended to 5 - 8 days.
Freezer compartment within a refrigerator-15°C (5°F)2 weeksThis is for freezers that do not have a separate door from the refrigerator.
Freezer with a separate door from the refrigerator-18°C (-0.4°F)3 monthsSome sources consider breast milk to continue to be safe at 6 months when stored at -18°C regardless of the type of freezer.
Deep freezer-20°C (-4°F)6-12 monthsStorage up to 12 months is considered acceptable but not widely recommended.

Breast milk from different pumping sessions may be safely combined, as long as the freshly expressed milk is properly chilled in the refrigerator before adding it to a container with previously expressed milk. [11] [4]

If expressed breast milk will not be used within the next 4 days, it should be frozen as soon as possible. The best way to freeze breast milk to minimize waste is by freezing in 2-4 ounce increments, and leaving about one inch of space at the top of the bag or container since the breast milk will expand when it freezes. [12] [11] When storing frozen breast milk, the door of the freezer should be avoided as this can subject the breast milk to temperature changes when the door is opened and closed. [12] The best spot in the freezer for storing breast milk is away from the sides and toward the back where the temperature remains the most constant. [11]

Breast milk can be safely transported in insulated coolers with frozen ice packs for up to 24 hours, after which it should be used immediately, stored in a refrigerator, or frozen. [12] The frozen ice packs must be in constant contact with the milk containers, and the cooler should not be opened unless absolutely necessary. [11]

Preparing breast milk for consumption

Thawing frozen breast milk

Frozen breast milk should be consumed in the order it was expressed; always using first the oldest milk available. [12] [11] Frozen breast milk should be prepared for consumption in one of three ways: slow thaw in the refrigerator, rapid water bath thaw at a temperature under 37°C, or running lukewarm water; it should not be thawed in a microwave. [10] [12] [4]

Once frozen breast milk has been thawed, it should not be re-frozen. [6] [10] If the breast milk was thawed in the refrigerator, it can be kept in the refrigerator for up to 24 hours. [12] The 24 hours start counting from the moment the breast milk is completely thawed, and not the moment it was taken out of the freezer. Milk from different frozen batches (that come from the same person) can be pooled once they have been thawed. [10]

Some handling practices have an impact on the reduction of total fat content, such as water bath thawing (8.5-18% total fat reduction) and microwave warming (8.5-31% total fat reduction), while room temperature thawing has been found to have no statistically significant change on total fat content. [17] Regardless of the technique, fat often separates in breast milk, so it should be swirled prior to serving to mix the fat back in. [12] [11]

Warming breast milk

Despite the widespread availability of breast milk warmers, breast milk does not need to be warmed - it can be served at room temperature or cold, if the baby accepts it. [12] [11] If breast milk is warmed prior to consumption, the temperature must always be checked to ensure it is at a safe temperature for the baby. This can be done by putting some drops of the breast milk on your wrist. [12]

The CDC recommends that if there is leftover milk from a feeding (baby did not finish the bottle), it should be used in the 2 hours after the baby finished feeding, or it should be discarded. [12] [4]

See also

Related Research Articles

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Infant formula, also called baby formula, simply formula, baby milk or infant milk, is designed and marketed for feeding to babies and infants under 12 months of age, usually prepared for bottle-feeding or cup-feeding from powder or liquid. The U.S. Federal Food, Drug, and Cosmetic Act (FFDCA) defines infant formula as "a food which purports to be or is represented for special dietary use solely as a food for infants by reason of its simulation of human milk or its suitability as a complete or partial substitute for human milk".

<span class="mw-page-title-main">Baby bottle</span> Bottle containing liquid (usually milk or formula) to nourish infant

A baby bottle, nursing bottle, or feeding bottle is a bottle with a teat attached to it, which creates the ability to drink via suckling. It is typically used by infants and young children, or if someone cannot drink from a cup, for feeding oneself or being fed. It can also be used to feed non-human mammals.

<span class="mw-page-title-main">Breast pump</span> Mechanical device used to extract milk from human breasts

A breast pump is a mechanical device that lactating women use to extract milk from their breasts. They may be manual devices powered by hand or foot movements or automatic devices powered by electricity.

<span class="mw-page-title-main">Breast milk</span> Milk produced by the mammary glands in the breast of a human female

Breast milk or mother's milk is milk produced by the mammary glands in the breast of human females. Breast milk is the primary source of nutrition for newborn infants, comprising fats, proteins, carbohydrates, and a varying composition of minerals and vitamins. Breast milk also contains substances that help protect an infant against infection and inflammation, such as symbiotic bacteria and other microorganisms and immunoglobulin A, whilst also contributing to the healthy development of the infant's immune system and gut microbiome.

<span class="mw-page-title-main">Breast engorgement</span> Medical condition

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The International Code of Marketing of Breast-milk Substitutes is an international health policy framework for breastfeeding promotion adopted by the World Health Assembly (WHA) of the World Health Organization (WHO) in 1981. The Code was developed as a global public health strategy and recommends restrictions on the marketing of breast milk substitutes, such as infant formula, to ensure that mothers are not discouraged from breastfeeding and that substitutes are used safely if needed. The Code also covers ethical considerations and regulations for the marketing of feeding bottles and teats. A number of subsequent WHA resolutions have further clarified or extended certain provisions of the Code.

<span class="mw-page-title-main">Supplemental nursing system</span>

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Infant feeding is the practice of feeding infants. Breast milk provides the best nutrition when compared to infant formula. Infants are usually introduced to solid foods at around four to six months of age.

<span class="mw-page-title-main">Infant food safety</span>

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<span class="mw-page-title-main">Establishment of breastfeeding</span>

Establishment of breastfeeding refers to the initiation of providing breast milk of mother to baby. According to the World Health Organisation(WHO), breastfeeding is the best way to provide nourishment, including essential nutrients, energy and antibodies, to infants and toddlers. The start of breastfeeding is supported by the milk production which depends on the development of internal and external breast structure and hormonal control on milk secretion. Besides milk supply, adopting the correct approach of breastfeeding helps build up the maternal bond, which in turn promotes breastfeeding. Not only does nursing strengthen the mother-child relationship, but it also improves the intelligence and immunity of breastfed children and diminishes breastfeeding mothers' risks to have ovarian and breast cancer.

<span class="mw-page-title-main">Hegen</span> A baby product brand in Singapore

Hegen is a Singapore brand incorporated in June 2014 that designs and produces breastfeeding pumps, storage containers, and bottles. Its flagship product is its Express-Store-Feed system with the patented Press-to-Close, Twist-to-Open (PCTO) technology. Its current CEO is its founder, Yvon Bock. Hegen was reported to be one of the top 10 fastest growing companies in Singapore and ranked #41 in the Financial Times "High-Growth Companies Asia-Pacific 2022".

<span class="mw-page-title-main">Hand expression of breast milk</span>

Hand expression of breast milk is a technique used by lactating mothers to express milk using their hands. It is an ancient practice that has been used by women across the world for centuries. Hand expression has gained renewed interest in recent years due to its affordability, portability, and effectiveness. It is an important tool for breastfeeding mothers, especially those who are unable to afford or access breast pumps.

References

  1. ↑ "Infant and young child feeding". www.who.int. Retrieved 2024-04-15.
  2. 1 2 3 American Academy of Pediatrics (July 2022). "Policy Statement: Breastfeeding and the Use of Human Milk". publications.aap.org. Retrieved 2024-04-15.
  3. ↑ Johns, Helene M.; Forster, Della A.; Amir, Lisa H.; McLachlan, Helen L. (2013-11-19). "Prevalence and outcomes of breast milk expressing in women with healthy term infants: a systematic review". BMC Pregnancy and Childbirth. 13 (1): 212. doi: 10.1186/1471-2393-13-212 . ISSN   1471-2393. PMC   4225568 . PMID   24246046.
  4. 1 2 3 4 5 6 7 8 9 10 11 12 13 Eglash, Anne; Simon, Liliana; The Academy of Breastfeeding Medicine; Brodribb, Wendy; Reece-Stremtan, Sarah; Noble, Larry; Brent, Nancy; Bunik, Maya; Harrel, Cadey; Lawrence, Ruth A.; LeFort, Yvonne; Marinelli, Kathleen A.; Rosen-Carole, Casey; Rothenberg, Susan; Seo, Tomoko (September 2017). "ABM Clinical Protocol #8: Human Milk Storage Information for Home Use for Full-Term Infants, Revised 2017". Breastfeeding Medicine. 12 (7): 390–395. doi:10.1089/bfm.2017.29047.aje. ISSN   1556-8253.
  5. 1 2 3 4 5 6 7 8 9 10 11 12 Peters, Micah D. J.; McArthur, Alexa; Munn, Zachary (2016-12-01). "Safe management of expressed breast milk: A systematic review". Women and Birth. 29 (6): 473–481. doi:10.1016/j.wombi.2016.05.007. ISSN   1871-5192. PMID   27318564.
  6. 1 2 3 4 5 6 Scott, Hayley; Sweet, Linda; Strauch, Leah; Muller, Amanda (September 2020). "Expressed breastmilk handling and storage guidelines available to mothers in the community: A scoping review". Women and Birth: Journal of the Australian College of Midwives. 33 (5): 426–432. doi:10.1016/j.wombi.2019.09.009. ISSN   1878-1799. PMID   31645302.
  7. 1 2 3 4 5 6 Meier, P P; Patel, A L; Hoban, R; Engstrom, J L (August 2017). "Which breast pump for which mother: an evidence-based approach to individualizing breast pump technology". Journal of Perinatology. 36 (7): 493–499. doi:10.1038/jp.2016.14. ISSN   0743-8346. PMC   4920726 . PMID   26914013.
  8. ↑ Johns, Helene M.; Forster, Della A.; Amir, Lisa H.; McLachlan, Helen L. (2013-11-19). "Prevalence and outcomes of breast milk expressing in women with healthy term infants: a systematic review". BMC Pregnancy and Childbirth. 13 (1): 212. doi: 10.1186/1471-2393-13-212 . ISSN   1471-2393. PMC   4225568 . PMID   24246046.
  9. ↑ Labiner-Wolfe, Judith; Fein, Sara B. (February 2013). "How US Mothers Store and Handle Their Expressed Breast Milk". Journal of Human Lactation. 29 (1): 54–58. doi:10.1177/0890334412453876. ISSN   0890-3344. PMID   22933609.
  10. 1 2 3 4 5 6 7 8 Canadian Agency for Drugs and Technologies in Health (June 2016). "Storage, Handling, and Administration of Expressed Human Breast Milk: A Review of Guidelines". National Library of Medicine. PMID   27336107 . Retrieved 28 April 2024.
  11. 1 2 3 4 5 6 7 8 9 10 11 12 La Leche League International. "Storing Human Milk". llli.org. Retrieved 2024-04-28.
  12. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 CDC (2023-04-17). "Proper Storage and Preparation of Breast Milk". Centers for Disease Control and Prevention. Retrieved 2024-04-28.
  13. 1 2 3 Food and Drug Administration (25 April 2022). "Cleaning a Breast Pump". FDA.
  14. ↑ CDC (2023-03-03). "Hand Expression". Centers for Disease Control and Prevention. Retrieved 2024-04-29.
  15. ↑ La Leche League International. "Hand Expressing". llli.org. Retrieved 2024-04-29.
  16. 1 2 Food and Drug Administration (February 2018). "Types of Breast Pumps". FDA.
  17. 1 2 3 Gao, Chang; Miller, Jacqueline; Middleton, Philippa F.; Huang, Yi-Chao; McPhee, Andrew J.; Gibson, Robert A. (July 2017). "Changes to breast milk fatty acid composition during storage, handling and processing: A systematic review". Prostaglandins, Leukotrienes and Essential Fatty Acids. 146: 1–10. doi:10.1016/j.plefa.2019.04.008. ISSN   0952-3278. PMID   31186148.
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