1. Human Milk Bank Processes: YOUR FACILITY AND LOCATION Gillian Weaver Milk Bank Manager President; European Milk Bank Association (www.europeanmilkbanking.com) Gillian.weaver@yahoo.com

2. @GillyWeaver Daughter, mother and breastmilk banker. Lots more besides but these three define me best....

3. QCCH Milk Bank The world’s longest continually operating milk bank

4. Our primary goal 93% discharged receiving breastmilk, 60% exclusively breast/breastmilk feeding

5. Background info Page 5 Brief description How did your human milk bank (HMB) began? When? 1935 but officially established in1939 Who provided initial funding? How are ongoing operations funded? Integrated into government services? Originally funded by ‘The National Birthday Trust Fund but is now funded by Imperial College Hospital NHS Trust (ICHNT). Some income is generated by reimbursement of costs by other hospitals who are provided with donor breastmilk. Who regulates /oversees HMB in your country/region (if any)? NICE guideline – implementation is audited How many HMBs are part of your system? Where are they? 17 milk banks in the UK Is there a central HMB that processes milk and distributes or many HMBs that process milk and distribute? (Centralized vs de- centralized) Several are more like a centralised model but most are decentralised. How many NICU/Neonatal wards/community homes does each bank serve? Are they collocated? It varies between 1 and 36 How many babies does your facility/system serve annually? Approximately 400 babies per year at ICHNT How many liters/year does your facility/system process annually? Processes 500 – 700 litres per year. How many donor mothers initiate donation to your facility/system annually? 150 +

6. A NICE Guideline Published in February 2010 with: UNG QRG Baseline Assessment Audit Support

7. Process Brief description of processes Staffing 1 x full time manager 1 x 0.8wte assistant (mainly administrative) 1 x 0.5wte assistant (mainly technical) 1 x volunteer for 2 hours per week (audit) Donor recruitment Donors contact the milk bank via the UKAMB website (www.ukamb.org), via local health care professionals or through word of mouth.www.ukamb.org Donor screening Telephone or face to face initial interview Detailed health questionnaire via email or post Blood tests (usually blood taken by local GP and posted to the ICHNT laboratory. Ongoing screening via health declaration made with each donation. Recipient eligibility and selection Preterm less < or = to 30/40 More mature babies who meet the pre determined criteria Handling and storage of donor milk (from donation to feeding) If in mothers’s home she is required to monitor and record freezer temperature If stored ina hospital in monitored freezer In milk bank: stored according to the stage in the milk banking process ie raw milk is stored separately from pasteurised milk, screened milk is separate from unscreened milk. All milk is stored separately according to the donor in demarcated and labelled baskets.

8. Process Brief description of process Transport of milk Via medical couriers, Via ‘Blood Bikes’, Milk Bank staff Use thick walled polystyrene containers sold for the purpose and with detachable outer carrying case. Tamper evidence is maintained and milk must be labelled with ID number of mother, date expressed and any medications taken. Pasteurization Purpose designed and built human milk pasteurisers (fully automated) with built in printer and in built milk cooling system. Have two. Pasteurise in 50ml and 100ml aliquots to prevent wastage. Tracking and record keeping Combination of electronic and paper. Use Excel spreadsheets to maintain records and to audit activity Assessing milk quality and safety (ie. microbiology assays) Pre pasteurisation Every pool of milk (500 – 800mls, single donor only) is tested Acceptance criteris are <100,000 cfu’s per ml in total < 10,000 cfu’s per ml staphylococcus aureus, enterobacteriaceae Post pasteurisation Sample from every batch should be <100cfu’s per ml. Quality assurance HACCP Audit of implementation of NICE guideline Double checking and authorisation of all test results Annual calibration of equipment and follow maintenance schedule

9. Preparing to test the donated breastmilk

10. Equipment/Location Brief description of process What is used/how many? Pasteurizer 2, Freezers 5 in the milk bank (lockable) Refrigerators 1 in the milk bank Additional HMB equipment requirements? 3 Secure rooms (1 only accessed by milk bank staff and 2 only accessed by milk bank or neonatal staff) 2 Computers Printer and label printers Referral/feeder/depot facilities? Other neonatal units in hospitals within the same perinatal network (6) Equipment requirements – monitored freezers Neonatal ward equipment requirements? System for tracking usage – no but every container of DBM has unique ID number and comes with spare self adhesive number labels that are peeled off and placed in baby’s medical notes and on separate tracking sheet. Freezer and fridge Other? Tamper evident containers, laminar flow cabinet, insulated transport containers with washable outer cases and handles,

11. Organizational Successes Page 11 Brief description of top 3-5 successes Policy Success of UKAMB nationally and UKAMB guidelines National guideline funded by Department of Health (NICE guideline CG93) DH Neonatal Toolkit (2009) – recommends access to DBM BLISS Standards for Neonatal Care - recommends access to DBM Operational Of the 46 Level 3 Neonatal Units in England the top five in terms of breastfeeding rates on discharge all have an attached milk bank Only 7% of infants are discharged from QCCH NNU (level 3) exclusively formula fed and 60% are exclusively breastmilk fed. Involvement of SERV groups (Blood Bikes – Volunteer motorcyclists, trained and co-ordinated to collect DBM from donors’ homes and transport to milk bank and deliver pasteurised donor milk from milk bank to other neonatal units QCCH – longest continually operating milk bank in the world Technology

12. Transporting DBM SERV (Service by Rider Volunteers) Freewheelers White Knights

13. Organizational Challenges Page 13 Brief description of top 3-5 challenges Policy Developing a robust donor milk use policy that optimises support for breastfeeding and supports all mothers to provide their own breastmilk whilst at the same time ensuring stocks aren’t compromised due to too liberal use nor stocks too plentiful due to too constrained use Operational UKAMB – attracting funding QCCH Milk Bank – maintaining consistent demand for DBM from other hospitals to enable further growth and development of the bank Space – very limited and restricts operations Technology introducing electronic testing and reporting systems into the milk bank at QCCH Introducing bar code tracking into the milk bank at QCCH

14. Fail proof identification and traceability are essential components of the 21 st century milk bank in the UK

15. Issuing DBM to the neonatal units of Imperial College Healthcare and to other hospitals

16. DONOR BREASTMILK: A very valuable resource!

17. Making every dropcount …..

18. and never forgetting where it all starts....