Expressed breast milk (EBM) is often used for feeding babies at BHS. As a body fluid, EBM has the potential for transmission of infection and pathogenic organisms. There are instances where a baby may receive a different mother's breast milk in error. Errors can occur due to incorrect labelling, incorrect identification of the baby or wrong selection of another mother’s milk.

This protocol outlines procedures to be followed in the event of incorrect breastmilk administration.

Risks associated with incorrect administration of breastmilk are minimised by immediate action and appropriate follow up of all affected parties.

This document should be read in conjunction with NCP0050 Blood and Body Fluid Exposure if further clarification is required.

EBM - Expressed breastmilk.

HBV - Hepatitis B virus.

HCV - Hepatitis C virus.

HIV - Human Immunodeficiency Virus.

CMV - Cytomegalovirus.

HTLV Type 1 and HTLV Type 2 - Human T-cell Lymphotropic Virus Types 1 and 2.

Recipient baby - The baby who received the incorrect breastmilk.

Birth mother - The mother who gave birth to the baby who received the incorrect breastmilk.

Source mother - The non-birth mother whose breastmilk was administered to the baby.

Types of Incidents to consider:

• Baby breastfed by another mother (not the birth mother).

• Baby has received expressed breast milk (EBM) from another mother (not the birth mother) - known as the source mother.

This guideline does not apply if:

• The baby is breastfed by or receiving EBM from a commissioning mother (not the birth mother) in the case of consensual surrogacy arrangements.

• The baby is receiving donor breastmilk sourced by and with the consent of its mother/carer. Please refer to the BHS CPP0395 Donor Breastmilk.

• EBM is a body fluid with the associated, but usually small risk of transmission of infection. Identification of an infectious agent in breastmilk is not necessarily proof of transmission.

• Transmission of HIV from single breast milk exposure has never been documented.

• Families should be informed that the risk of transmission of infectious diseases via breast milk is small.

• Possible infections which may be transmitted through breastmilk include: Hepatitis B Virus (HBV), Hepatitis C Virus (HCV), Human Immunodeficiency Virus (HIV), Cytomegalovirus (CMV) and Human T-cell Lymphotropic Virus I/II (HTLV I/II).

• Babies are more likely to be exposed to identity errors due to their age and possible length of hospitalisation.   

• Babies who are separated from their mothers are more likely to be at risk of receiving incorrect breastmilk (e.g. babies in Special Care Nursery).

• Storage, transport and checking of EBM should be done in accordance with the BHS CPG0186 Breastmilk - Expressing, Storing and Feeding. Following an incident of incorrect EBM administration, this policy should be reinforced to all staff who care for babies and causal factors (e.g. staff shortages, inadequate checking procedure) identified and managed to prevent further incidents.

1. Immediate response:

• Discontinue feed.

• If baby is being fed by nasogastric tube and incident is identified at time of feeding, contents may be aspirated immediately.

• Do not insert a nasogastric tube for the sole purpose of aspirating the feed.

2. Notification and documentation

Notify the following people:

• Nurse Unit Manager / Shift Co-ordinator / Patient Flow Co-ordinator (after hours).

• Medical staff.

• Infection Prevention and Control.

Documentation:

• Document all details of the event, discussions and actions in the baby's progress notes.

• Complete a VHIMS/Riskman report and ensure infection control department is on the distribution list.

• Confidentiality must be maintained - do not identify the names of birth or source mothers to each other.

3. 3. Arrange for a medical officer to provide the following:

• Arrange for open disclosure, apology and counselling for all parties (see NCP0024 Open Disclosure).

• Inform birth mother and source mother of the incident as soon as possible.

• Reassure all parties that the risks of transmission of infection is minimal. Refer to Appendix 1. - Information about infections and breastmilk.

• Discuss with birth mother and source mother the recommendation for serum screening of both.

• Obtain informed consent from birth mother and source mother for serum screening. Source consent form MR/056.0 should be completed by source mother - see appendix 4.

• Offer complaint/feedback form to both birth mother and source mother.

• Arrange for pre and post serum screening counselling by a medical officer for both birth mother and source mother.

4. 4. Risk assessment of source mother completed by the medical officer

Conduct a risk assessment of the source mother as soon as possible after the event in order to inform screening, further management and counselling. Refer to Appendix 2 - Risk assessment of the source mother.

5. Non-consent to serology screening by source mother

• In this event, the case must be referred to the Executive Director of Medical Services and Infection Prevention and Control. (see NCP0050 Blood and Body Fluid Exposure).

• If risk assessment (see point 4 above) indicates high risk of source mother being positive for any infections, manage incident as though source mother is positive. See Appendix 3 Serology results and subsequent management.  

6. Serum Screening
Screening should be done as soon as possible so that appropriate treatment for the baby is commenced if required.

6.1 Tests to be performed on both the birth mother and and source mother:

• Hepatitis B surface antigen (HBsAg) and Hepatitis B core antibody.

• Hepatitis C antibodies.

• HIV antibodies.

• CMV antibodies if the recipient baby is < 32 weeks (at birth), or below 1500gms (birth weight) or immunocompromised.

• Consider Human T-cell Lymphotropic virus I/II (HTLV I/II) if risk factors present. Refer to Appendix 1. - Information about infections and breastmilk. Consult Infectious Diseases specialist if risk factors present.

Important note: Pathology request slip should be marked URGENT as some treatments need to be commenced within four hours of exposure.

6.2 Tests to be performed on the baby who received the incorrect breastmilk:

• This should be determined on a case by case basis depending on risk assessment completed by the medical officer and serology results, and in consultation with an infectious diseases physician.

• Initial serum screening of the baby is not required. Once serum screening of birth and source mother results are known, refer to Appendix 3 Serology results and subsequent management.  

6.3 Outcome of Results - See Appendix 3 Serology results and subsequent management:  

• The doctor ordering the initial serology testing must follow up the results.

• Review the antenatal screening results and current screening results of the birth mother and the source mother.

• A doctor must inform the birth mother and source mother of results in person (not via phone), without disclosing the identity of either party to each other.

• If any serology results are positive, consultation with a specialist infectious diseases physician is required.

• Depending on results of screening, management and ongoing counselling should be implemented as per Appendix 3  Serology results and subsequent management and Appendix 1. - Information about infections screened for when incorrect breastmilk is administered to a baby.