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Q: Breast milk Mixup ( Answered,   1 Comment )
Subject: Breast milk Mixup
Category: Health > Medicine
Asked by: elizalaw-ga
List Price: $10.00
Posted: 26 Jul 2004 12:06 PDT
Expires: 25 Aug 2004 12:06 PDT
Question ID: 379280
I looking for articles or cases about hospital mixup of breastmilk
given to hopitalized infants?
Subject: Re: Breast milk Mixup
Answered By: librariankt-ga on 28 Jul 2004 11:01 PDT
Hi Elizalaw,

There have been a few news reports (available on the web) about milk
mixups, as well as other items published on the web.  I'm providing
you links below, as well as some citations to items not available
online but most likely at your local university or large public

Australian hospital tested baby for HIV after feeding wrong mother's milk 
Agence France-Presse - May 1, 2004
The same story from an Aussie news outlet:
And the press statement from the hospital (sorry about the ugly URL):

Family Reports Breast-Milk Mix-Up At WakeMed
NBC-17 (TV) - June 25, 2003

The best practices document from the Hospital for Sick Children:

Here's a lawsuit complaint of a woman who was given the wrong baby to

REPORT OF THE MONTH, Volume IV, Number 6
November-December 2000
from the North Carolina Statewide Program for Infection Control and Epidemiology
"Banked Breast Milk Given to the Wrong Baby 
Q: What should be done if banked breast milk is given to the wrong
baby in the nursery? Is this an exposure?
A: No guidelines exist specifically for the post-exposure management
of infants accidentally exposed by ingestion of breast milk. However,
situations in which human milk is collected from unrelated donors for
infant feeding have prompted the development of guidelines for
appropriate selection and screening of donors as well as practices for
careful collection, processing, and storage of the breast milk.
Currently, U.S. donor milk banks that belong to the Human Milk Banking
Association of North America voluntarily follow guidelines drafted in
consultation with the U.S. Food and Drug Administration and the
Centers for Disease Control and Prevention. These guidelines
summarized in the Pediatric Red Book include screening donors for
antibodies to HIV-1, HIV-2, HTLV-I, HTLV-II, HBsAg, hepatitis C, and
syphilis. The Statewide Program for Infection Control and Epidemiology
(SPICE) recommends that it would be prudent to follow these guidelines
for the post-exposure testing of the source of the human milk, with
the exception of syphilis, as long as these results were already
available from the prenatal screening. Also, SPICE suggests that the
source should be tested for HSV if lesions are present on the donor
breast. Of course, a policy that is enforced to rectify the situation
from occurring again is paramount. UNC Healthcare has a protocol that
allows only the nurse assigned to the baby to prepare (i.e., thaw) and
deliver the milk to the baby after carefully cross-checking the infant
identification bracelet number to the milk identification number."

Apparently this is perceived to be a serious enough problem that there
are companies out there ready to sell hospitals a product to prevent

These websites I found by doing the following searches of the Google engine:
"wrong breast milk" hospital
"wrong breastmilk" hospital
"breast milk" "wrong mother" hospital
"breast milk" "wrong baby" hospital

I found these articles in the CINAHL database:

"From breast to baby: quality assurance for breast milk management.
By: Dougherty D. NEONATAL NETWORK: The Journal of Neonatal Nursing,
2000 Oct; 19(7): 21-5 (journal article - protocol)
Abstract: Breast milk is a body fluid capable of transmitting
blood-borne pathogens when ingested. High-risk infants are frequently
fed mother's expressed breast milk and may be at risk if they receive
the wrong mother's milk. A multidisciplinary team at this 42-bed Level
III regional NICU developed a quality assurance program and audit
aimed at reducing the risk of feeding expressed breast milk (EBM) to
the wrong high-risk infant in the unit. Changes to the old system
included modernizing the handling, storing, and distribution of EBM.
Elimination of feeding errors was the priority. A specific protocol to
minimize EBM feeding errors became part of the quality assurance
program and is consistent with the recommendations of the NICU
multidisciplinary team."

"Formula feed preparation: helping reduce the risks; a systematic
review. By: Renfrew MJ. ARCHIVES OF DISEASE IN CHILDHOOD, 2003 Oct;
88(10): 855-8 (journal article - research, systematic review,
Abstract: AIMS: To assess what is known about the risks associated
with errors in reconstituting the present generation of infant formula
feeds, and to examine which methods are likely to be safest. METHODS:
Systematic review, and examination of the range of infant formula
products currently on sale in the UK. Studies from developed countries
conducted after 1977 were included. All studies investigating the
reconstitution of formula feeds for full term, healthy babies were
eligible. Parameters studied were: measures of accuracy of feed
reconstitution including fat, protein, total solids, energy content,
and osmolality of feed; weight of powder in scoop; and reported method
of preparing feed and measuring powder. Formula products were
collected from one large UK supermarket in 2002. Number of different
types of infant formula preparations available for sale were
determined, together with scoop sizes for powdered preparations.
RESULTS: Only five studies were identified, none of adequate quality
or size. All found errors in reconstitution, with a tendency to
over-concentrate feeds; under-concentration also occurred. Thirty one
different formula preparations were available for sale in one UK
supermarket, with a range of scoop sizes. Some preparations had never
been tested. CONCLUSIONS: There is a paucity of evidence available to
inform the proper use of breast milk substitutes, and a large array of
different preparations for sale. Given the impact incorrect
reconstitution of formula feeds can have on the health of large
numbers of babies, there is an important and urgent need to examine
ways of minimising the risks of feed preparation."

"Management of expressed breast milk: is the right breast milk being
fed to infants? [corrected] [published erratum appears in CAN J INFECT
CONTROL 1998 Summer; 13(2): 63]. By: Barry C. CAN JOURNAL OF INFECTION
CONTROL, 1998 Spring; 13(1): 16-9 (journal article - tables/charts)
Abstract: Women's College Hospital has implemented a unit dose
dispensing system and quality assurance (QA) program for the
management of EBM. The primary objective was to ensure that infants
received the breast milk from their own mothers. The secondary
objectives included improvement of aseptic practices and temperature
control in the management of EBM. Introduction of a unit dose
dispensing system for EBM with a QA component demonstrated previously
undetected errors. A "Breast Milk Incident Policy" including parent
notification and screening for pathogens transmissible by EBM, was
developed to address the follow up for infants who received breast
milk other than from their own mother."

"Hospital tightens bottle procedures. Australian Nursing Journal,
Jun97, Vol. 4 Issue 11, p10, 1/4p;
Abstract: Reports on the tightening of procedures for use of expressed
milk in Gold Coast Hospital in Australia after a milk switching
incident. Incidents of milk mix-ups; Procedure used by the hospital
for identifying mother and baby; Implementation of new procedures to
prevent mix-up incidents."

"Infect Control Consult. Breast milk mix-up may warrant HIV follow-up
in child care. HOSPITAL INFECTION CONTROL, 1997 May; 24(5): 71-4
(journal article - practice guidelines, protocol)"

My searches in CINAHL  varied but used the same keywords mentioned for
the search of Google, above.  Unfortunately for the CINAHL articles
all I can provide you are the citations and abstracts - for copyright
reasons I can't copy the full text for you.

Please let me know if I can further clarify this question!

Subject: Re: Breast milk Mixup
From: pinkfreud-ga on 26 Jul 2004 12:11 PDT
Is this the kind of "mixup" that you have in mind?

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