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Jun 25, 2024
AN innovative system which prevents babies receiving expressed breast milk (EBM) from the wrong mother is set to be used by the NHS.
Milk360 also ensures infants don’t receive expired EBM which in the worst cases can lead to a fatality.
The system utilises breast-to-baby tracking technology and will soon be used by healthcare staff at Liverpool Women’s Hospital.
Its creators say it can help prevent the mistakes which are plaguing some NHS trusts and potentially leaving them open to costly compensation claims.
Details of the planned roll-out in Liverpool comes just six weeks after reports emerged of an incident in the south west of England where a baby was given EBM from a patient who wasn’t his mother.
NHS officials later admitted they gave the newborn boy EBM “from another donor in error”.  His mother had been undergoing an iron transfusion after giving birth when the mix-up happened.
The hospital apologised but had to conduct tests on the patient whose EBM they incorrectly used. A separate investigation found similar mix-ups repeatedly happened at other hospitals in the south west.
According to a report published by the Infant Journal, there were 13 cases where an infant received the wrong mother’s EBM between 2012 and 2018 at hospitals in the region.
Matt McAlister, from MSoft, the developer of Milk360, said this is a dangerously underreported issue, which the NHS urgently needs to take more seriously.
He said: “Unless hospitals make changes to the way they are administering EBM then, sadly, we are likely to see more cases of mistakes being made.
“Errors can happen for lots of reasons. Some wards are overstretched, they may be grappling with budgetary pressures and the issue of managing EBM may be low on the agenda. Hospitals may also have systems where they just manually manage the issue and hope they don’t make mistakes. Now they have a way of ensuring they can deliver a better service for mothers and for babies.”
“Technology can help eliminate errors”
Milk360 manages the safe collection of milk from a mother’s breast, then ensures the cold chain management through to the infant in the incubator. As well as ensuring the right milk reaches the right infant it also monitors the temperature of the EBM, checks that it has not expired and records any additives which have been added to it.
Mr McAlister said: “Expired breast milk can be incredibly dangerous if given to a bay. Bacteria can grow and make it unsafe for the baby and it can leave a child incredibly sick and unwell. In the worst-case scenario could even lead to a baby mortality.
“Additionally, all sorts of essential nutrients and antibodies are also passed from the mother’s milk so it’s vital the right milk is delivered to the right baby.”
“This really, really matters because from the parents’ point of view, we must remember this is a donated human product and it needs to be treated as such. It’s a finite resource that’s been provided for the baby to allow that baby to grow and leave the neonatal ward in a healthy state. To do that, healthcare staff need to make sure that they’re feeding these vulnerable, neonates with EBM from their mother, and also that it hasn’t expired.”
EBM is classified as a body fluid and must be handled at all times by up to two health care professionals (HCPs) who have been assessed as competent in accordance with their hospital standards. As a minimum, one of these should be a registered nurse or birthing specialist who is a member of staff in that hospital area. Currently in the UK EBM is recommended to be a two-person checking procedure at all steps of the process.
Mr McAlister said: “Breast milk is considered a human product and the maternity healthcare environment now accepts that mistakes are made and that technology can help to eliminate those errors with experience and knowledge.
“Breast milk tracking is now becoming more and more a necessity and is even included in the HIMSS Level 6 accreditation. This means there is now a requirement to perform positive patient identification at the cot-side making sure the milk expressed by the mother is fed to their infant. Milk360 manages the safe collection of milk from the mothers breast, then the cold chain management of that milk through to the infant in the incubator.”
Mr McAlister said Milk360 had also been designed to support NHS staff working with the tiniest newborns.
“In many cases the babies on neonatal wards are so small they can’t have wristbands on. It’s very difficult for nurses to uniquely identify these babies. So we have a process where we either scan a barcode on the incubator, or we ask a number of questions of the nursing staff before they administer milk.”
“Like a guardian angel for overworked nurses”
Crucially, Mr McAlister said Milk360 is designed to support nursing staff.  “NHS staff are human beings and they make mistakes like you and I,” he added. “This system is like having a guardian angel on the shoulder which act as a second checker.
“It is widely reported that droves of nurses are leaving because the pressure is on. They’re understaffed. The reason expired units are being administered or milk is reaching the wrong baby is often because staff are dealing with so many competing tasks in such a rush on the neonatal ward. This system helps make their job easier, will eliminate mistakes and therefore reduce the chances of trusts being hit with complaints and compensation claims in the future.”

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