LLLI Revises Milk Storage Guidelines (2008)
Betty Crase, BA, IBCLC, RLC
Hemet CA USA
Sara Dodder Furr, MA, IBCLC, RLC
Lincoln NE USA
From: LEAVEN, Vol. 44, No. 3, 2008, pp. 2-4
A mother may need to express her milk to feed to her baby for a variety of reasons. Common reasons include the need to express milk for a baby who is unable to feed directly at the breast or for a baby separated from his or her mother (e.g., when the mother is employed or attending school). According to the World Health Organization, "the best food for a baby who cannot be breastfed is milk expressed from the mother's breast."1 Any human milk which is not given to the baby immediately after being expressed must be stored.
Guidelines for storing human milk were revised by La Leche League International in June 2008. The information from this tear-off sheet follows this article. As with all LLLI tear-off sheets, this new informational sheet cannot be photocopied or reproduced in any way, but it can be downloaded by La Leche League Leaders for use in individual helping situations from the LLLI Community Network, where it is stored in the Publications Library. When multiple copies of the guidelines are needed, it can be purchased in pads of 50 sheets from the LLLI Online Store (http://store.llli.org/).
The revisions to the LLLI milk storage guidelines are the result of an exhaustive literature review by LLL Leader Betty Crase, with assistance from Carol Kolar, LLLI Director of Education. Betty sought input from Anne Eglash, MD, FAAFP, FABM, and members of the LLLI Professional Advisory Board/Health Advisory Council.2 Another participant in the literature review was Karen Butler, an LLL Leader with LLL of Great Britain and a member of the LLLGB Leaflet Team. At the same time Betty was updating the LLLI Storing Human Milk tear-off sheet, Karen was updating the LLLGB Storing Your Milk information sheet (available from http://www.lllgbbooks.co.uk/).
The updated Storing Human Milk tear-off sheet from LLLI should be considered a work in progress. As new research is published that is applicable to healthy, full-term babies, LLLI will revisit the guidelines and update them as necessary. The following questions and answers provide useful background information to explain the new guidelines.
Why do these guidelines differ from previous recommendations from LLLI, as well as other guidelines, such as those from pump manufacturers, the Academy of Breastfeeding Medicine (ABM), the US Centers for Disease Control (CDC)?
There has never been a time when there has been agreement or consensus among health professionals, organizations, government agencies and health ministries, and the research about the storage and handling of human milk. That is why LLLI has always reviewed the research and consulted knowledgeable members of the LLLI Professional Advisory Board/Health Advisory Council, other experts, and the positions of other organizations. Once information from these sources is compiled, it is examined side-by-side with the collective experiences of mothers and healthy full-term infants (who comprise the majority of those helped by LLLI) in order to determine guidelines for storing human milk.
The investigation of optimal human milk storage is open for further research. It is hoped that the new guidelines from LLLI, a lay breastfeeding organization, might spearhead renewed interest in milk storage guidelines. Perhaps other organizations will choose to revise their own protocols based on the review of the research by LLLI.
Previous guidelines from LLLI, as well as current guidelines from other organizations, show varying lengths of time for safe storage of human milk at different temperature settings. The new LLLI guidelines only have three temperature categories (room temperature, refrigerator and freezer), with a range of times for each. Why is that?
The research is varied with limited numbers of samples, different storage temperatures, and durations. Various studies base conclusions on whatever temperature(s) the researchers happen to be exploring, different conditions, different components and/or contaminants of human milk being investigated, etc. A thorough reading of various published guidelines suggests that the same research studies have been interpreted differently by various organizations, depending on whether the recommendations are specific for healthy, full-term or compromised infants, or are being generalized for all infants. The newly revised LLLI guidelines provide evidence-based ranges for the storage of milk that will be given to full-term, healthy babies.
Why is there only one general recommendation regarding storing human milk in a freezer versus guidelines that vary according to the type of freezer being used?
The reality is that there simply isn't any good research on the various types of freezers (free standing versus within a refrigerator versus separate door refrigerator/freezer versus self-defrosting or non-self-defrosting). Dr. Eglash, who was the lead author of the ABM 2004 Protocol #8, "Human milk storage information for home use for healthy full-term infants"3, advised that the 2008 LLLI guidelines should omit anything other than the single, overall freezer recommendation because there is too much variation and no hard evidence regarding which freezer type and temperature is superior.
Is it really safe to recommend that a baby (even one who is full-term and healthy) can be fed expressed human milk that has been left at room temperature for eight hours, refrigerated for up to eight days, or that has been frozen for 12 months?
One very important consideration is the totality of human milk versus infant formula for optimal infant nutrition, growth, and development -- even if one component of human milk or another isn't at an optimal level after certain storage and handling conditions. LLLI recommendations affect mothers and babies all over the world in all kinds of living and working conditions. Globally (including within the USA), there are mothers who lack access to freezers, refrigerators, or coolers with blue ice for a long day of work. It is hard to reconcile the possibility of telling mothers who are separated from their infants to discontinue breastfeeding, or at least expressing their milk, and have their infants receive infant formula (possibly prepared incorrectly or in unsanitary conditions or with contaminated water) in questionable environments.
LLLI is not aware of any research studies or case reports documenting spoiled or highly contaminated human milk sickening infants after storage under more liberal guidelines, including those recommended by LLLI for years, such as storing milk for up to eight days in the refrigerator. The real challenge is trying to find some common ground and common sense between the research and the real life situations around the world in which breastfeeding mothers live and work.
At the same time, LLLI feels a strong sense of responsibility to share the most pertinent, evidence-based, clinically relevant recommendations with LLL Leaders and mothers. Providing sound recommendations within the public health arena is one important aspect of the equation; providing sound recommendations for individual mothers of healthy, full-term infants is another.
According to the information sheet, the revised guidelines "provide evidence-based ranges for the storage of milk." What does this mean?
Many people equate being "evidence-based" solely with being "research-based." Evidence-based guidelines are broader in scope than research-based guidelines. The premise behind "evidence-based" is that all key factors -- including research, clinical practice, personal experience, cultural and demographic realities -- are taken into consideration in formulating guidelines. LLLI has a long history of successful breastfeeding practices and the experiences of millions of breastfeeding mothers and babies around the world from which to draw.
What has really changed about the milk storage guidelines? What is important for LLL Leaders to understand about why the revisions were made?
La Leche League Leader Betty Crase was instrumental in working with Michaelene Gerster Trocola, LLLI Publications Editor, to revise the Storing Human Milk tear-off sheet. According to Betty, it was important that the revised guidelines present:
- A range of storage options.
- The varying interpretations of existing research.
- The protection of human milk against many diseases without emphasizing allergies. The relationship between allergies and breastfeeding is not emphasized in the new guidelines since recent clinical reports question the extent of the relationship between breastfeeding and allergy risk beyond exclusive breastfeeding for four to six months.4 These reports also suggest there is no benefit to maternal dietary restrictions during lactation unless the infant is at high risk of developing allergies.
- The lack of research about the common practice of re-using human milk that was left over then refrigerated after a previous feeding, as well as the lack of research about how to handle freshly expressed milk which has not been completely used during a feeding.
- Information about the enzymatic activity that may make some mothers' thawed milk smell or taste soapy and how to deal with it.
- Information about how to handle human milk expressed during an outbreak of thrush.
How can these revised guidelines be reconciled with the public health approach to storing human milk, which tends to advocate shorter times for safe milk storage?
A strict public health approach, encouraged in many countries, results in guidelines that are more conservative. The question becomes, "Should we tell women to forget about breastfeeding and feed their infants formula if the mothers, for example, must keep their expressed milk at room temperature for longer than four hours -- perhaps with no (or unreliable) access to refrigeration/cooling packs -- or if their milk has been refrigerated longer than 72 hours?" A comprehensive review of the literature leads to the conclusion that there is no evidence to support the idea that formula feeding is preferable to feeding expressed human milk in these circumstances. Indeed, although research may indicate that human milk is safe when stored at a certain temperature for a certain period of time, studies are often limited in that they do not continue beyond the given time period. It is important to consider the possible harm of implying that infant formula is superior to expressed human milk unless storage conditions are ideal, given the limited state of the research about human milk storage and the fact that LLLI helps mothers and babies around the world, not just in the USA. When asked, experts consulted for review of the revised guidelines agreed that human milk would be better than infant formula under almost any circumstances. This is the bottom line message that must not be lost in the shuffle as we debate the research.
1. Facts for Life, World Health Organization, www.unicef.org/ffl/04/6.htm
2. The members of the LLLI PAB/HAC who provided valuable comments and research guidance are Armond Goldman, MD, FAAP; Judy Hopkinson, PhD, IBCLC; Ruth A. Lawrence, MD, FAAP, FABM, FAACT; Paula P. Meier, RN, DNSc, FAAN; Jack Newman, MD, FRCPC; Richard J. Schanler, MD, FAAP and Christina Smillie, MD, FAAP, FABM, IBCLC.
3. www.bfmed.org/Resources/Download.aspx?filename=Protocol_8.pdf [link updated for website]
4. Greer FR, Sicherer SH, Burks AW, and the Committee of Nutrition and Section on Allergy and Immunology. Effects of Early Nutritional Interventions on the Development of Atopic Disease in Infants and Children: The Role of Maternal Dietary Restriction, Breastfeeding, Timing of Introduction of Complementary Foods, and Hydrolyzed Formulas. Pediatrics 2008; 121(1):183-191.
Storing Human Milk for Babies in the NICU
When a mother is expressing milk for her baby who is hospitalized in the Neonatal Intensive Care Unit (NICU), she should follow the milk storage guidelines recommended by the hospital or the physician caring for the baby. NICU guidelines are more stringent than the new LLLI guidelines. For example, some NICU milk storage guidelines found online suggest that human milk should only be left at room temperature for one hour. NICU guidelines also typically recommend that thawed milk be fed to baby within 24 hours.
Using Common Sense to Safeguard Expressed Milk
Although human milk has antibacterial properties, it is still important to use common sense when handling expressed milk and pumping equipment. For example, it is important to wash hands thoroughly with warm, soapy water before handling expressed milk. Pump parts should be cleaned as directed, in a place where contamination by other bacteria is least likely to happen. (This may mean, for example, not using the bathroom as a place to handle expressed milk or to clean pump parts.) Pump parts should be sterilized once a day or as recommended by the manufacturer.
Breastfeeding and Expressing Milk through Separation
It is possible to continue to breastfeeding, even if you need to be separated from your baby for a day or longer. There are a variety of pumps available for mothers to use when traveling. If you are traveling by air in the US, there are some guidelines from the Transportation Security Administration which outline how to transport your milk. Check www.tsa.gov/travelers/airtravel/children/formula.shtm for the most recently updated guidelines. Or read the overview at www.llli.org/Release/tsabreastmilkpolicyupdate.html.
In general, mothers flying with or without their child will be permitted to bring breast milk in quantities greater than three ounces as long as it is declared for inspection at the security checkpoint.