Management of Human Milk in Child Care Settings
Three important considerations emerge regarding the management of human milk in child care settings:
- A safe environment for children and the child care workers who provide care for them is important. The American Academy of Pediatrics, American Public Health Association, and National Resource Center for Health and Safety in Child Care and Early Education recommend that child care workers follow the guidelines published in the 2011 Caring for our children: National health and safety performance standards; Guidelines for early care and education programs, 3rd Edition.i
- Breastfeeding has been identified as an important “upstream” intervention that affects the health and well-being of babies and their mothers. The California Department of Public Health (CDPH) recommends that babies be fed only breast milk for the first six months of life.ii iii Breast milk together with healthy foods is recommended to continue after six months, for as long as the mother and baby desire.
- The number of women in the work force is increasing and therefore societal adaptions will occur in many arenas related to women and motherhood. In California, the National Association of Child Care Resource and Referral Agencies’’ report entitled: 2010 Child Care in the State of Californiaiv states that the number of women in the labor force who had a birth in the past 12 months was: 275,080. Although over 90% of California women initiate breastfeeding, rates of exclusive breastfeeding drop dramatically at 3 monthsv , a time when women generally return to work. Child care centers’ policies to support breastfeeding are essential if breastfeeding rates among mothers who are returning to work are going to improve. For this reason, breastfeeding support policies are included in “Preventing Childhood Obesity in Early Care and Education Programs.”
There is no current evidence of child care workers or others contracting a life-altering illness through exposure to human milk in child care centers. Child care workers follow guidelines published by the Department of Labor Occupational Safety and Health Administration (OSHA) and the Centers for Disease Control and Prevention (CDC). OSHA’s (29 CFR 1910.1030) Occupational Exposure to Bloodborne Pathogenslife,vi states, “Breast milk is not included in the standard's definition of "other potentially infectious materials".” Therefore, contact with breast milk does not constitute occupational exposure, as defined by the standard. This determination was based on the Centers for Disease Control's findings in Perspectives in Disease Prevention and Health Promotion Update: Universal Precautions for Prevention of Transmission of Human Immunodeficiency Virus, Hepatitis B Virus, and Other Bloodborne Pathogens in Health-Care Settings,vii that human breast milk has not been implicated in the transmission of the human immunodeficiency virus (HIV) or the hepatitis B virus (HBV) to workers although it has been implicated in perinatal transmission of HIV and the hepatitis surface antigen has been found in the milk of mothers infected with HBV. For this reason, gloves should be worn by health-care workers in situations where exposures to large volumes of breast milk might be frequent, for example, in milk banking.”
The Human Milk Banking Association of North America (HMBANA) recently published Best Practice for Expressing, Storing and Handling Human Milk in Hospitals, Homes and Child Care Settings.life.viii These Best Practices state, “Gloves are not recommended for handling human milk except when large volumes are handled, such as during processing milk in a donor milk bank. Use of gloves does not replace the need for good hygiene. Change gloves if they touch contaminated surfaces, to avoid contamination of the milk.” The rationale cited by HMBANA is “Occupational exposure to human milk has not been implicated in the transmission of HIV, hepatitis, or other viruses found in human milk. Universal precautions do not apply. Careful hand hygiene is still important.” … “Gloves can give the wearer a false sense of security, which may increase the possibility of contamination of the milk. In situations where gloves are worn, hand hygiene is still important because the gloves can be contaminated by the wearer.”
The Academy of Breastfeeding Medicine’s (ABM) Clinical Protocol #8: Human Milk Storage Information for Home Use for Full-Term Infantsix states: “Expressed human milk does not require special handling (such as universal precautions), as is required for other bodily fluids such as blood. It can be stored in a workplace refrigerator where other workers store food, although it should be labeled with name and date.”
The guidelines published in the 2011 Caring for our children: National health and safety performance standards; Guidelines for early care and education programs, 3rd Edition.i “Although human milk is a body fluid, it is not necessary to wear gloves when feeding or handling human milk. Unless there is visible blood in the milk, the risk of exposure to infectious organisms either during feeding or from milk that the infant regurgitates is not significant.”
Current policies and practices in hospitals require staff to maintain universal hand washing precautions – but do not require their staff to wear gloves every time they must feed an infant human milk or help the mother to breastfeed.x Despite the number of child care workers as well as the decades of experience with human milk handling in hospitals and human milk banks (1,000 ounces per day), human milk has never been implicated in the occupational transmission of HIV or HBV infection. When gloves are used in human milk banks, the rationale is not due to protection of the workers handling the milk but rather to protect the milk from contamination.life.xi Current recommendations are for health care workers to advise mother’s infected with HIV disease not to breastfeed. The possibility of transmission of HIV from mother’s breast milk in a childcare facility is low.life.xii
There is a risk of unintended consequences should further restrictions that lack an evidence base, be implemented. If child care workers were erroneously trained on addressing breast milk with all the elements required by the OSHA blood borne pathogens standard (29 CFR 1910.1030), a series of unintended consequences could occur:
The use of gloves can give child care workers the false security that hand washing is not necessary, even though hand washing is the primary means of prevention of the spread of infections far beyond those that might be transmitted through the breast milk.life.viii
Due to the necessity to work, mothers would stop providing breast milk to their child in order to be able to have access to essential child care, but will then expose their infant to a less-optimal nutrition choice in order to be able to keep their child in day care.
Fewer infants would be exclusively breastfed once their mothers returned to work. This would be despite the expenditure of funds to develop and implement campaigns by the California Department of Public Health and the US Department of Health and Human Services that promote and provide support to health care providers, women and the community so that mothers are successful throughout their breastfeeding experience.
- Fewer child care centers would care for breast milk fed infants, reducing the availability of child care to mothers who are breastfeeding, due to
Unless clear evidence demonstrates the need to change current practices, it is important to avoid the development of new guidelines that might discourage child care agencies from supporting breastfeeding mothers or create fear of caring for breastfeeding infants.
Science has not substantiated that exposure to human milk is a danger to child care workers, and the use of gloves when feeding breast milk is not supported by current research. Therefore, based on the references reviewed and cited above, adherence to the following recommendations provides protection for both the infant and care giver when handling human milk:
- Care should be taken to wash hands and feeding tools (e.g., bottles, spoons, etc) before and after handling human milk, as one should with any other food that is being offered to infants and young children in a child care setting.
- Care should be taken that human milk is labeled with child’s name and date expressed so as to avoid errors of giving an infant someone else’s milk. Similar care practices are already in place so that children are given the appropriate foods and avoid erroneously giving a food to a child who is allergic or whose parents have given specific instructions (vegetarian, religious, cultural reasons).
- Breast milk should be stored safely as for all food products. See CDC’s “Proper Handling and Storage of Human Milk” at (http://www.cdc.gov/breastfeeding/recommendations/handling_breastmilk.htm). They provide details on 1) safely preparing and storing expressed breast milk, 2) safely thawing breast milk, and 3) storage duration and temperature of fresh human milk for use with healthy full term infants. These guidelines are also referenced in the 2011 Caring for our children: National health and safety performance standards; Guidelines for early care and education programs, 3rd Edition.i
i American Academy of Pediatrics, American Public Health Association, National Resource Center for Health and Safety in Child Care and Early Education. 2011. Caring for our children: National health and safety performance standards; Guidelines for early care and education programs. 3rd edition. Elk Grove Village, IL: American Academy of Pediatrics; Washington, DC: American Public Health Association. Available at http://nrckids.org/CFOC3/CFOC3_color.pdf (PDF, 46.6 MB)
ii California Food Guide: Fulfilling the Dietary Guidelines for Americans. Sacramento, California: California Department of Health Care and California Department of Public Health; 2008. Available at http://www.cafoodguide.ca.gov/
iii California Department of Public Health Administrative Manual (PHAM), Chapter 4, Lactation Accommodation, Section 4-2114, June 2011. Available at http://cdphintranet/FormsPubs/Documents/Publications/PHAM/Chap04,Sec02-Attendance-PHAM.pdf (PDF)
iv National Association of Child Care Resource and Referral Agencies, 2010 Child Care in the State of: California Available at http://www.naccrra.org/publications/naccrra-publications/publications/8880000_State%20Fact%20Bk%202010-states.pks_CA.pdf (PDF)
v California Department of Public Health. Maternal, Child and Adolescent Health Needs Assessment for the Title V Block Grant 2011-2015. Maternal, Child and Adolescent Health Program and Center for Family Health, California Department of Public Health. http://www.cdph.ca.gov/programs/mcah/Documents/MO-MCAH-NeedAssessment-v6-10-15.pdf (PDF): s.n., 2011.
vi Roger A. Clark, Director, Directorate of Compliance Programs, United States Department of Labor, correspondence December 14, 1992. Available at: http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=INTERPRETATIONS&p_id=20952
vii Perspectives in Disease Prevention and Health Promotion Update: Universal Precautions for Prevention of Transmission of Human Immunodeficiency Virus, Hepatitis B Virus, and Other Bloodborne Pathogens in Health-Care Settings. MMWR June 24, 1988, 37(24):377–388. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/00000039.htm
viii Human Milk Banking Association of North America: “Best Practice for Expressing, Storing and Handling Human Milk in Hospitals, Homes and Child Care Settings” 2011 3rd Edition © HMBANA. Available at: http://www.hmbana.org/
ix The Academy of Breastfeeding Medicine’s (ABM) Clinical Protocol #8: Human Milk Storage Information for Home Use for Full-Term Infants, Breastfeeding Medicine, Volume 5, Number 3, 2010,ª Mary Ann Liebert, Inc. Available at: www.bfmed.org/Media/Files/Protocols/Protocol%208%20-%20English%20revised%202010.pdf (PDF)
x Personal Communication with Caroline J. Chantry MD, Professor of Clinical Pediatrics, University of California Davis Medical Center, July 1, 2011.
xi Personal communication with Pauline Sakamoto, R.N., M.S., Executive director, Mothers Milk Bank, in San Jose, CA and Past President of the Human Milk Banking Association of North America’s Board & Advisory Council June 29, 2011.
xii The Centers for Disease Control and Prevention. Human Immunodeficiency Virus (HIV), and Acquired Immunodeficiency Virus (AIDS). Available at: http://www.cdc.gov/breastfeeding/disease/hiv.htm