Intervention to Prevent Breast Milk Misappropriation in a Tertiary Care Center

Background: Breast milk misappropriation (BMM) is an infrequently reported biological fluid / medication error. There is limited medical literature in looking at interventions to prevent BMM and the results of workup of BMM.

Objective: To examine the factors involved with a failure of an intervention to prevent BMM at a tertiary care center and potential infectious disease complications. 

Methods: Community based Teaching Hospital with a 50 bed Newborn Intensive Care Unit (NICU) and 16 bed Convalescent Nursery Unit (CNU); retrospective review of infant and maternal charts, pre-natal testing, post-incidence serology of HIV 1/2, Hepatitis B and C, RPR, HTLV I/II, and CMV obtained on recipient and donor mothers of BMM, interviews with nursing personnel from January 1, 2005 to October 31, 2009, with a focus on the period from December 2007 after intervention to prevent BMM by instituting a Nutrition Room and electronic monitoring.

Results: Rates of BMM in incidents /feeding were 3.3x10^-5 for 2005, 1.1 x10^-4 for 2006, 2x10^-5 for 2007 before intervention, approximately one BMM every 2-5 months. The rate after intervention was “0” for 2008 and 7.3x10^-5 for January to October 2009, represented as three BMM’s within 3 months. Investigations in the failure of the intervention revealed a break in policy due to inconvenience of placement of electronic monitors and spillover of bins in the nutrition room. Regarding possible infections, all tests were negative except for CMV. For CMV, 12/17 available tests were positive; however there was no instance where the donor mother was CMV positive and the recipient mother CMV negative.

Conclusions: 1) In dealing with BMM, the use of a combination of electronic monitoring and resource specific dispensing was initially successful in decreasing rates of exposures; however, these methods remained subject to human error. 2) Clarity of administrative controls (written policies) and engineering controls (design of rooms and placement of equipment) must be considered when designing interventions. 3) No exposures to those blood-borne pathogens tested for occurred as a result of BMM that may not have already occurred previously from their own mother's breast milk.