Best Practice for Order of Use of Human Milk in NICU/Hospitals

Patrice Hatcher, MBA, BSN, RNC-NIC / May 2018

Efficient use and storage of human milk is a priority in the NICU. Newborn infants separated from their mothers and requiring special care related to illness or prematurity are often too fragile to breastfeed.

The benefits of an exclusive human milk diet are well documented. When mothers are not available to breastfeed, it becomes imperative to measure, track, and efficiently use all of mother’s available breast milk.

Many NICUs are moving to an exclusive human milk diet that includes donor human milk (D-HM) when mother’s own milk is not available. The cost of D-HM can be prohibitive for some hospitals because the cost in many states is not reimbursed by insurance.

The question is: Do you know which stored milk to feed first?

Order of use situations

There are times in the NICU when clinicians are faced with the challenge of order of use. Which container of breast milk should be used first to feed, when multiple containers of expressed milk are available and the patient is only fed breast milk?

I’ll outline two situations for your consideration. Can you assess which order to feed?

Situation 1:  Mother brings in recently pumped expressed breast milk to the patient bedside, and multiple containers of breast milk that was previously prepared with additives is available in the refrigerator. The question or dilemma that may be present is which milk to use first. Fresh milk (never frozen), offers more immunomodulary proteins, and breast milk with additives has a shorter shelf life.1

Situation 2:  Donor human milk is available on the unit. It has been thawed and prepared during the previous shift for the next several feeds, and containers are available in the refrigerator. Or, the father of your patient brings in a special delivery of fresh and frozen breast milk for your patient after D-HM has been prepared and in the refrigerator.

Both situations can present challenges for which container of milk to use first. I’ll answer which is best at the end of the blog.

Often when fresh milk is available, the desire is to feed the freshest breast milk and hold the prepared milk for the next feed. Not wasting any of this valuable resource is the priority in the NICU. Careful thinking through the best practice is critical. Is there an alternative to make for efficient use of all the milk? We want to use all of mother’s milk and not waste prepared milk or donor human milk.

Mothers work very hard to pump, collect, label, and deliver milk to their infants. It is so important to deliver every drop to their baby. Exclusive breastfeeding is an enormous commitment, and mothers work diligently to pump and deliver milk to the NICU for their baby.

Order of Use for Breast Milk in NICU

  1. Previously thawed milk
  2. Milk prepared with fortifier
  3. Fresh milk / Mother’s own milk
  4. Colostrum: Colostrum is the priority, use in an organized manner. Identify milk as colostrum on the patient label for the first two weeks after birth date.
  5. Oldest milk first: The FIFO method, use the first in/first out.
  6. *D-HM: If it has been thawed and prepared with fortifier. Use before it expires.

The third edition of Human Milk Banking Association of North America’s (HMBANA) Best Practice for Expressing, Storing and Handling Human Milk in Hospitals, Homes, and Child Care Settings, recommends “clearly marking mothers expressed milk over the first four weeks following birth.”1 Clearly labeled containers with markings will aid in prioritizing milk containers for order of feeding. NICUs that develop a novel approach to identify containers of colostrum ensure that all early containers of milk (colostrum) is fed to baby.

Robbins and associates describe a process for identifying colostrum, transitional, or mature milk by using specialty colored stickers and numbering the colostrum container so milk can be fed to the baby in the order the milk was expressed.2 Adopting a similar practice allows the inventory of milk to be used in a consistent and orderly fashion.

In response to the two situations presented above, the best response (although it may not present as the most obvious response) is to use the prepared breast milk.

  • Unfortified, fresh milk is safely stored in the refrigerator for 96 hours at 4 degrees celsius3
  • Breast milk that is fortified and refrigerated is safe for 24 hours

The most efficient way to use all of mother’s milk is to first feed the previously prepared and fortified breast milk. The fresh milk can be stored in the refrigerator and available for use immediately following all prepared bottles of milk.


Looking for more on this topic? Read NICU Human Milk Preparation: Do We Need Dedicated Milk Technicians?

*when available    


  1. Jones, F. Best practice for expressing, storing and handling human milk in hospitals, homes, and child care settings. Human Milk Banking Association of North America. (3rd Ed). 2011.
  2. Robbins ST, Meyers R.  Infant feeding: Guidelines for preparation of human milk and formula in healthcare facilities.  American Dietetic Association. (2nd Ed.) 2011.
  3. Slutzah M. et al. Refrigerator storage of expressed human milk in the neonatal intensive care unit. J Pediatrics. 2010; 156: 26-28.

About the Author

Patrice Hatcher MBA BSN RNC-NIC

Patrice Hatcher, MBA, BSN, RNC-NIC, began her practice more than 24 years ago as a neonatal nurse working in NICU. She has experience in various nursing leadership roles including neonatal transport nurse, outpatient nurse manager, and administrative nurse manager overseeing operations of large intensive care units. She has special interest in quality improvement and improving clinical outcomes for neonates. Patrice currently works full-time as a Clinical NICU Specialist for Medela LLC.

6 thoughts on “Best Practice for Order of Use of Human Milk in NICU/Hospitals

  1. Do you have information that you can share to support the Breastmilk with additives being safe for use for 24 hours?
    Our current practice is much less time and I would like to present information to have it changed.

  2. Patrice Hatcher, blog author says:

    Sure I will refer to the Human Milk Banking Association of North America (HMBANA). Best Practices for Expressing, Storing and Handling Human Milk in Hospitals, Homes and Child Care Settings (2011) often refereed to as guidelines or recommendations for HM storage duration in refrigerator. The recommend, HM that has been fortified for NICU & high risk infants freshly expressed and previously frozen (thawed and not warmed) – time in the refrigerator = 24 hours. Up to 24 hours /not exceed twenty-four hours. Hope this source is helpful with evaluating practice, please let me know if you have any additional questions. Patrice

  3. Some of our micro premie moms produce more than 4 days worth of colostrum, especially since the infant is getting such tiny amounts. We end up freezing some of the colostrum. Is is better to defrost and use up all the colostrum first rather than start giving transitional fresh milk?

  4. Patrice Hatcher, blog author says:

    Great question, I am so glad you asked. In 2012, O’Malley published a paper in the Neonatal Intensive Care journal addressing order of use and why, I will quote her here “colostrum has higher concentrations of anti-infective, anti-inflammatories, growth factors and other protective substances than does term colostrum. It should be fed as soon as possible in early feedings. The first milk is especially important and should be labeled and fed in order of expression.” Also, Human Milk Banking Association of North America (HMBANA) 2011, recommend using colostrum and oldest milk first. Thawing and feeding E-BM in the order of expression will ensure all milk is used efficiently and colostrum is fed to infant. In my personal experience, and I will add this was a while ago, at a hospital where I worked we discharged an infant home after being in the NICU for months still having containers colostrum. It was disappointing to see that this infant had not received the benefits of all of mothers colostrum. We immediately corrected our process for labeling and using colostrum to ensure all of mothers milk pumped in the first two weeks was clearly identified and used in order of expression. Hope this helps. Patrice

    • Hi Melinda, thank you for bringing this to our attention! The references were intended to be posted but were missed when the blog post published. The blog post has now been updated with the original references Patrice used.

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