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Iredell Health System

Policy & Consent for use of Human Donor Milk

Inspire Wellbeing — Together

The Birth Place
Human Donor Breast Milk
To provide guidelines for use of human donor breast milk (HDBM) for infants
whose mothers own milk is unavailable or in low supply.

1. HDBM comes sterilized in a packet and should be stored at room
2. Each packet of HDBM contains four ounces of sterilized milk.
3. Once open, the milk should be poured in to four individual one ounce
food grade containers. These containers of milk are good for use for 7
days. Any containers of milk left after 7 days will be discarded.
4. The individual containers of HDBM should be labelled with contents, lot
number, and date to discard (seven days after opening).
1. If a mother chooses HDBM for supplemental feedings and supplemental feedings
become necessary:
a) Sanitize preparation area.
b) Obtain a packet of HDBM and supplies from storage.
c) Wash hands prior to preparing HDBM.
d) Open milk and pour into 4-one ounce containers and apply label (as described
under “storage”).
e) Place 3 of the containers to the breastmilk refrigerator.
f) Make an entry in to the Human Donor Breast Milk Log in the nursery. This will
include the date, infant identity label, and lot number.
g) Obtain other supplies (cup, syringe, etc.) and take the fourth container to the
patient’s room for supplementation.
h) Small amounts of milk (5-10 ml) are all that should be needed for
supplementation during the first few days of life. Limiting supplementation to
this small amount will ensure the infant will not be overfilled and will be
hungry for the next feeding.
i) Document amount of HDBM given to infant and lot number in the infant’s
j) Donor human milk that is left over after feeding is good for 2 hours stored at
room temperature and then should be discarded.
k) HDBM should not be provided for patients to take home.
Mother’s Plan for Breastfeeding Infant
The goal during your stay is to establish breastfeeding. If you are planning to add bottle feeding, we encourage you
to wait to do so until your baby has learned to latch well and you have established an adequate milk supply.
My plan and preference is to breastfeed my infant. _______________________________________________
Mother’s Signature Date

Supplementation may be recommended and necessary for some of the following medical indications:
• Late pre-term birth or prematurity and baby not latching or breastfeeding well.
• Confirmed low blood sugar in infant not resolved by breastfeeding.
• Maternal illness
• Decreased voids and stools
• High bilirubin level or jaundice
• 10% weight loss before discharge
The goal of supplementation is to add to the mother’s feedings, not to replace them. Supplement can be given by a
syringe or small cup, using small amounts of pasteurized human donor milk or formula.
Supplementation with Pasteurized Human Donor Milk:
• Donor milk is breast milk that is donated by mothers who have extra.
• Medolac, the donor milk bank, used by Iredell Health System (IHS) completes a comprehensive health
screening on the donors who provide the human milk and tests donors every six months for Human
Immunodeficiency Virus (HIV), Hepatitis B and C, Human T-cell Lymphotropic Virus (HTLV) and Syphilis.
Donors are determined to be healthy to donate milk by their health provider.
• The donated breast milk is processed using a type of pasteurization in specially-designed equipment that
ensures the safety of the milk while not affecting the quality of the milk.
• Medolac processed milk is homogenized which increases fat absorption by the infant.
• Medolac donor milk is commercially sterile.

If supplementation becomes necessary for my infant, I consent and prefer for my infant to be given
Medolac human donor milk

Mother’s Signature Date
Supplementation with Formula
Formula is made with cow’s milk or is plant or soy based. IHS provides three major brands of formula
- Gerber Good Start, Enfamil and Similac. The US Food and Drug Administration (FDA) regulate the
commercial infant formula companies to ensure minimum nutritional and safety requirements are met.

If supplementation becomes necessary for my infant, I prefer and consent for my infant to be
given Gerber Good Start Enfamil Similac formula.
Mother’s Signature Date

Signature of Witness Date Time

Mother’s Plan for Breastfeeding Infant

Iredell Health System

STATESVILLE, NC 28677-1828
Phone 704-873-5661
The Birth Place Iredell Health System

Sterile Human Donor Breast Milk

What is donor breast
Donor milk is breast milk donated
by mothers who have more milk
than they can feed their infant.

Is donor breast milk

Maintaining high levels of quality of
human donor milk is important at
Medolac. With the most strict Milk
Banking Safety and Quality Program
in the world, Medolac standards
include testing every drop of milk.

Breastfeeding is Best!
• 100% Breast Milk But sometimes, it may be recommended and necessary for babies
to have supplementation during the first few days of life.
Supplements are given in small amounts to “add to” the mother’s
• Homogenized feeding, not to replace the mother’s feedings.

• Pasteurized Indications for supplementation include:

• Born late preterm (between 34 and 37 weeks gestation)
• Commercially Sterile • Low blood sugars which is not resolved by breastfeeding
• High bilirubin levels or jaundice
• 10% weight loss before discharge
• Decreased voids and stools
• Maternal illness

When the baby requires more milk than the mother is making,
human donor breast milk is a natural choice.
M edola c
A Public Benefit Corporation
Lake Oswego, Oregon
Medolac completes a comprehensive health screening on donors
If you have questions about the who provide the human milk. Donors are tested every six months
milk your baby receives, contact
M e d o l a c d i re c t l y a t 8 6 6 - 5 5 9 - 7 7 4 0 for Human Immunodeficiency Virus (HIV), Hepatitis B and C,
or visit Medolac.com Human T-cell Lymphotropic Virus(HTLV) and Syphilis.