Expert: Sally Wendkos Olds - 1/28/2009

Question
My husband gave my baby breast milk that was out on the counter for about 20 hours! She hasnt vomited but I think shes not feeling well. She ate fine the rest of the day, coudl she really get sick from this.

Answer
Dear Brandi,

First, congratulations for giving your daughter the best start in life with your good breast milk!

Second, if the milk that your husband gave her didn't smell obviously sour to him, it was probably all right. You don't say how old your baby is and whether she's eating/drinking other foods as well, which could affect her reaction to the milk. Watch her closely for the next couple of days, and if anything about her behavior or appearance seems worrisome, call your doctor.

I'm attaching guidelines for storing and feeding expressed breast milk from the manuscript for the 4th edition of my book (see below).

Good luck!

Sally
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Sally Wendkos Olds
Author, THE COMPLETE BOOK OF BREASTFEEDING: Eiger & Olds, 3rd edition 1999, published by Workman Publishing & Bantam Books, and available in most public libraries, bookstores & La Leche League chapters. Now in revision for a fourth edition, with pediatrician Laura M. Marks, M.D.
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Storing Collected Breast Milk
Containers
The best containers for storing your breast milk are four-ounce plastic BPA-free nursing bottles. With many pumps the expressed milk goes directly into these bottles. They’re solid and sturdy, and a safer way to store breast milk than plastic milk storage bags, which can become contaminated with bacteria if they get bumped by anything sharp, such as the edge of an ice cube. Most pumps collect milk in bottles that you can use for both storage and feeding.
• BPA-free plastic has an advantage over glass. For one thing, of course, plastic doesn’t break when dropped, and you don’t want to waste that liquid gold. In addition, if you’re storing your milk for less than twenty-four hours, you want plastic bottles, since some research suggests that some of the leukoyctes (white blood cells) in breast milk cling to glass, making them unavailable to your baby. They don’t cling to plastic. However, the cells detach from glass after about twenty-four hours. So if you’ll be storing your milk that long or longer, the composition of the container doesn’t matter.
• You want the small four-ounce bottles rather than the eight-ounce ones, so that you can defrost small amounts of milk at a time. Once thawed, milk should not be refrozen.
• Some women like the disposable milk storage bags made especially for storing breast milk. These bags lie flat in a freezer, are easy to stack, and thaw quickly. However, other mothers find them hard to handle and easy to puncture, and if they are punctured there’s a danger of contamination. The bags need very careful handling to avoid spillage and puncture, they sometimes split when frozen, and they absorb odors from nearby foods (although babies don’t seem to mind milk that smells like the garlicky sausages in the next container). Double-bagging or putting the bags in a freezer-quality zipper bag may overcome some of these difficulties.

Cleaning and Sterilizing
If you’re collecting milk to be given to your own baby within one week, you don’t need to sterilize bottles, nipples, and pumping equipment. Wash everything thoroughly with a bottle brush and nipple brush to remove any milk scum, and then wash in a dishwasher or a basin of hot soapy water. Wash nipples on the top rack. Rinse out all the soap.
  If you’re going to take milk to the hospital for a sick or premature baby or for donation to a milk bank, the hospital or milk bank will probably give you instructions. If not, or if you want to freeze the milk for your own future use, sterilize your containers and equipment. If you have a dishwasher that uses water heated to 180° Fahrenheit (82° Celsius), this will sterilize everything well enough. Check to be sure all the pump parts can be safely washed in the dishwasher.
  To sterilize just a few things, pad the inside of a large soup pot with a clean towel and fill it with enough water to completely cover the items you’re sterilizing (bottle, cup, bottle caps, nipples, funnel, etc.). Bring the water to a boil over high heat; then turn down the heat just enough so that the water continues to boil gently. After five minutes of boiling, remove the nipples with sterile tongs. Place them on a clean dry towel. Allow the other items to boil fifteen minutes longer. Do not touch the rims of the bottles or the insides of the caps.

Helpful Suggestions
• Use a nontoxic marker to label each container of frozen milk with the date so you’ll use the oldest milk first. If you’re taking it to a baby-sitter, child-care center, or hospital, put your baby’s name on it.
• Don’t fill bottles or storage bags to the top. Milk expands as it freezes, so no more than three and a half ounces should go into a four-ounce bottle.
• You can collect milk a little at a time, chill it in the refrigerator, and add the cold milk to milk that’s already frozen. It will have an interesting layered or striped look that won’t affect its quality and will disappear after it’s thawed and swirled. Be sure to chill new milk first before adding to frozen milk, since adding warm milk can defrost the top layer of the frozen milk.
• You can also freeze milk in a plastic ice cube tray covered by plastic wrap. The frozen cubes (about half an ounce to an ounce each, depending on the size of the compartments) can then be transferred to an airtight plastic or glass container or a sturdy plastic bag. When you or your sitter is ready to feed your baby, put the number of cubes you need into a feeding bottle and defrost as described below. This way you have more flexibility, since you can defrost only what your baby needs at one time. Since the cubes defrost quickly, it’s easy to add another one if your baby still seems hungry.

Transporting Expressed Milk
Although milk will keep at room temperature for several hours, it’s always safest to keep the milk cold. You can do this whatever way is most convenient for you—in a thermos, an insulated bottle bag, an ice chest, or an insulated bag filled with ice cubes or ice packs. Check the method you’re using to be sure that the milk is still cold when it arrives at its destination and that frozen milk is still frozen.

Offering Expressed Milk to Your Baby
Both you and anyone else who feeds your baby your collected breast milk need to know the following information, so you may want to photocopy these pages to have them handy.
  Don’t be alarmed by the appearance of stored breast milk. It often separates, looks striped, or turns yellow, any of which may be perfectly normal. If you’re not sure about the quality of the milk, smell it and taste it. If it tastes sweet and good, it’s fine. If it has a soapy smell due to the enzyme lipase, which breaks down milk fats, it’s still safe. Babies usually don’t mind this taste, but if yours does, the next time you express milk you can scald it by heating it almost to boiling (bubbles around the edges), and then quickly cool and freeze it. Sometimes milk may smell because it has picked up an odor from other strong foods in your refrigerator or freezer. Trust your senses and your own good sense: If you smell anything like sour cow’s milk, the milk has gone bad, and you don’t want to give it to your baby.

Storage Times for Collected Milk
Basically, your collected breast milk will keep for several hours at room temperature if it’s covered; it will keep in the refrigerator for three days; and if you want to keep it longer than that, freeze it.
The longer you store milk, the less nutrition it will give your baby, so it’s best to use your milk as soon as possible. It’s also better to feed your baby refrigerated milk than frozen milk, since freezing may destroy some of breast milk’s anti-infective properties. If you’re expressing and storing milk for a preterm infant or a hospitalized baby, follow the recommendations of the institution where your baby is being cared for or has recently been discharged from.

Storing Freshly Expressed or Pumped Breast Milk
• To be given to baby within 4 hours: Ideally, cool or refrigerate as soon as possible after expressing, but if necessary it can be kept at room temperature, even in a warm room (66° to 79°F or 19° to 26°C).
• To be given to baby within 4 to 10 hours: Pour into a clean container; cap tightly. If convenient, refrigerate the milk or put it in a cooler with frozen ice packs. This is the safest course, even though human milk kept in a capped clean container does not grow bacteria at normal room temperature (66° to 72°F or 19° to 22°C) because of its bioactivity, its ability to slow the growth of bacteria. If the room temperature is higher than 72°  (22°C), refrigerate it.
* To be given to baby within 24 hours: Immediately put milk in a clean container and cap tightly, and as soon as possible put it in a cooler with frozen ice packs; refrigerate when you arrive home.
• To be given to baby within 1 week: Pour into a clean container; cap tightly. Refrigerate at 40°F (4°C) or below. Although it should keep well for a week, ideally if you want to keep it longer than three days, it’s best to freeze it.
• To be given to baby within 3 months: Pour into a clean container; cap tightly. Quick-cool in the refrigerator for 30 minutes. Then freeze in refrigerator-freezer unit.
• To be given to baby within 6 months: Pour into a sterile container; cap tightly. Quick-cool in the refrigerator for 30 minutes. Then freeze at 0°F (-18°C) or below in the freezer of a two-door refrigerator or a deep freeze that is not opened often. Not all freezers stay cold enough for long-term storage. Check the temperature with a freezer thermometer at different places in the unit. The freezer should maintain a constant temperature of 0°F. If it keeps ice cream very solid, it’s probably cold enough.
  If your freezer does not get this cold but does keep other frozen foods hard, keep the milk in the center of the freezer and use within three to four months. Frost-free refrigerators, which have a warming element, generally do not maintain 0°F (-18°C) – see “igloo” suggestion on page tk.
  To find out whether your milk thaws and then refreezes in your freezer, check by keeping an ice cube in a little jar; if you check it a day later and find that it no longer has the shape of the cube but that it has melted and refrozen, you’ll know that this has probably happened to your milk, too. Smell the milk to see if it’s still good. If you’re in doubt, discard it.
  Use milk as soon as possible after collecting it. Ideally, you won’t keep it longer than three months. For one thing, milk collected when your baby is two months old won’t meet her needs as effectively when she’s six months old – although it’s still better than formula!
• Keeping breast milk longer than 6 months: This is not a good idea. While instructions are sometimes given for keeping frozen milk up to two years, long-term freezing alters the chemical composition of the milk. (Some of the fats break down, and the milk loses some of its ability to fight harmful organisms.) Furthermore, you run the risk of contamination if you lose electrical power during that time and the milk thaws and refreezes.
• Do not refreeze milk that has defrosted: If frozen milk has started to thaw, refrigerate it immediately and use it within 12 hours.

Storing Milk That Has Been Frozen and Thawed in Refrigerator
•   Do not refreeze, do not thaw at room temperature, and do not store in cooler.
•   To be given to baby within one hour: Keep in container in refrigerator, or cooler, or at room temperature.
•   To be given to baby within 24 hours: Keep in container in refrigerator.  

Storing Milk That Has Been Thawed and Warmed
•   Do not refreeze and do not store in cooler.
•   To be given to baby right away: feed baby.

Milk That Has Been Warmed and Left in Bottle after Feeding
•   Do not store. Throw away any milk left in a bottle because organisms from the baby’s mouth can contaminate the rest of the milk. This is why it’s best to store expressed milk in small quantities.

Defrosting Your Milk and Feeding Your Baby
• About half an hour before feeding time take the container from the freezer and hold it under tepid running water. Gradually increase the temperature of the water to hot. Swirl the bag or bottle gently as you warm it; this remixes the cream that has separated. (Since your milk is not homogenized, the fat rises to the top on standing. It should take about four minutes to thaw four ounces of frozen milk. This method can also be used to heat refrigerated milk.
•  Do not leave frozen milk out at room temperature to defrost. Even leaving it in the refrigerator overnight may result in spoiled milk.
• Do not heat either breast milk or formula in a microwave oven. Vitamins and other components in the milk may be destroyed, glass bottles may crack or explode, and hot spots may occur, which could cause severe burns to your baby’s mouth or esophagus.
• Do not heat milk on the stove. First, there’s a danger of overheating and destroying
antibodies and nutrients. Second, there’s the chance that frozen milk will curdle. And then there’s the all-too-common scenario of the mother or baby-sitter warming milk in a pan of water on the stove, running to answer the phone or the door—and coming back to find the bottle or bag melted and the milk boiled into the bottom of the pan. No way to treat that precious nectar—or the baby waiting for it.
  If you don’t have running warm water, heat water in a pan, and when it’s warm turn off the heat and put the bottle in the pan with the warm water. Test the milk on the inside of your elbow; you should barely be able to feel it. If it feels too warm, let it cool down to body temperature before feeding your baby.
• Roll or swirl the bottle again gently before feeding.
• Use milk that has been defrosted but not heated within 12 hours. If the milk has been heated, use within 30 minutes.
• Discard any milk in the bottle that your baby does not finish at one feeding.
• Do not refreeze defrosted milk. If you can’t use it within the suggested time limit, throw it away. It’s painful to have to discard what seems like such a precious resource, but this milk is no longer the liquid gold it was before. There’s a possibility that it might make your baby sick.
• If you have both fresh and frozen milk, give your baby the fresh milk and save the frozen for supplements and emergencies since freezing causes some loss of antibodies.