Breast Milk Misappropriation: Prevention and Mitigation 

The benefits of breast milk, as a source of nutrition for all infants, have been well established in the literature. However, the benefits of breast milk are amplified for premature or critically ill infants cared for in a Neonatal Intensive Care Unit (NICU). 

The evolution of breast milk collection and storage has undergone tremendous change in the past several decades as neonatal critical care has advanced clinically, and digital platforms have entered the health care arena. What started out decades ago as bottles or bags of collected breast milk stored in a NICU freezer basket with a lone patient label has been replaced with collection containers individually labeled with bar codes complete with an electronic medical record (EMR) interface. 

Given the frequency at which breast milk feedings are administered to infants in NICUs, there can be numerous opportunities for error. Staff inattention, improper bin placement, illegible bottle labels, and scanner malfunctions have all been problematic and can result in a neonate receiving milk from an incorrect source. To decrease these occurrences, the establishment of a breast milk management system and milk bank are most beneficial for safe practice. 

Breast milk is milk expressed by a mother for consumption by her own infant. The 5 Rights of Administration must be in place prior to feeding to prevent a NICU infant receiving milk from an incorrect source:

Right Patient: Patient ID band and medical record number verified to feeding order name and medical record number.

Right Milk: Breast milk bottle label name and medical record number verified to patient ID band name and medical record number.

Right Dose: Breast milk concentration (fortified/not fortified) and volume verified to feeding order.

Right Route: Mouth care, PO, NG, ND, GT, continuous, bolus verified to feeding order.

Right Time: Breast milk not expired. Time and frequency verified to feeding order and schedule.

Although misappropriation of breast milk is not widely reported, it nonetheless does occur in the NICU setting. Any instance of incorrect milk administration has the potential to result in the transmission of infectious diseases such as cytomegalovirus (CMV), human immunodeficiency virus (HIV) or Hepatitis B. In addition, misappropriation errors can lead to increased costs for testing to determine if disease transmission has occurred. There can be emotional distress for a mother whose infant received incorrect breast milk. Lastly, levels of family satisfaction are impacted during a NICU hospitalization given loss of trust in the health care team. 

If misappropriation occurs, a hospital facility must have a policy and procedure in place to address the error. For clarity, a donor mother is a mother whose expressed breast milk was unintendedly ingested by an infant other than her own. The recipient mother is the mother of the patient that received breast milk not personally expressed by her.

Individual hospital policies and situational variables may differ, but the following steps describe the essential elements for handling a hospital-based breast milk misappropriation:

  • Confidentiality of donor mother and recipient mother must be maintained, if possible, by hospital staff
  • An attending physician/authorized prescriber must disclose the breast milk misappropriation to both the donor mother and recipient mother at separate meetings
  • The attending physician/authorized prescriber will review the donor mother’s prenatal labs results prior to informing recipients mother of the misappropriation
  • The aspiration of the infants’ stomach contents immediately after the misappropriation may be considered if a nasogastric, oral gastric or gastrostomy tube is already in place upon order of the attending physician/authorized prescriber
  • The attending physician/authorized prescriber is responsible for notifying the department of epidemiology and infection control of the misappropriation
  • The donor mother should be tested for HIV, Hepatitis B core antibody, Hepatitis B surface antigen and Hepatitis C antigen regardless of prenatal lab results. If the donor mother refuses testing, then the recipient infant, with the mother’s consent, should be tested for the labs listed above. If the donor mother is Hepatitis B positive, the recipient infant should receive HBV immunoglobulin and HBV vaccine as soon as possible unless already administered.  
  • The attending physician/authorized prescriber should notify risk management and the hospital lactation coordinator of the occurrence. 
  • Documentation of the recipient’s infant exposure to the incorrect breast milk should be entered into the medical record as well as any refusal for testing by either the donor mother or the mother of the recipient infant.

In summary, any instance of breast milk misappropriation is a stressful event for NICU staff and parents and not without potential harm. Therefore, it is essential to implement systems to ensure safe practices at the delivery level. Considerable strides have been made to prevent breast milk misappropriation over the past decades with the evolution of labeling systems and creation of milk banks, but continued efforts are necessary. 


Hartmann, B. Ensuring Safety in Donor Human Milk Banking in Neonatal Intensive Care. Clinics in Perinatology 2017, 44, 131-149. 

DeMarchis A, Israel-Ballard K, Manson K, Engmann C. Establishing an Integrated Human Milk Banking Approach to Strengthen Newborn Care. Journal of Perinatology 2017, Vol 37, 469-474. 

Reimers, P. Coutsoudis A. Donor Human Milk Banking-Time to Redirect the Focus. Journal of Human Lactation 2021, Vol 37 (1) 71-75.