Thoughts on warming milk in the NICU - page 2

I am looking to you all for your honest thoughts. We have been looking at the Medela Waterless Warmers for our unit and for the most part, thought they were fine. We decided to be fiscally... Read More

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    From “Noteworthy Professional News”
    By Laura A. Stokowski, RN, MS

    In many neonatal units, nurses use polysterene foam cups full of hot tap water to warm up expressed breast milk for feeding. This low-tech method of warming creates many problems. The milk can become too warm, but more often remains too cold because we are too busy to rewarm the water. This method is not ideal for frozen milk. Not infrequently, we knock over cups of water at the bedside. And let us not forget that we are filling our landfills with styrofoam.

    Leave it to a nurse to come up with a better solution. The Penguin Nutritional Warmer™ (Neonatal Product Group, Overland Park, Kansas) [now Creche Innovations] is a unit of 4 receptacles, or wells, that hold sterile warming bags. Each well is individually controlled on separate LED key pads, allowing 1 or more to be used at a time, gently warming the milk to precise body temperature. The Penguin gently vibrates the milk, mixing milk, milk fat, and proteins, eliminating hot spots in the bottle for a controlled, even temperature. A soft alarm sounds and an LED displays the temperature and elapsed heating time when the milk reaches body temperature. The Penguin can be used for breast milk, formula, or any other liquid. It will hold the temperature for 30 minutes, so if the baby falls back to sleep or the feeding is delayed for some reason, the feeding remains warm.

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    Quote from TiffyRN
    Absolutely a legitimate question. I don't know about other units, but the unit where I work had an issue with an infectious outbreak. Though it could never be proved (all water sources and sites were cultured), it was felt that city water could not be trusted to come into contact with milk bottles or on infant's faces or mouths (even for routine bathing).

    Until we got the medela warmers, the only option for warming cold milk was to set the feed in an infant's isolette if one was lucky. Also, some areas (not all), had a warming cabinet, but it took approximately 1 minute per ml to adequately warm a cold feed.

    Thawing frozen milk was a particularly long and frustrating process taking hours (usually 2-3 hours for a full bottle). We were only allowed to set the bottle out on the counter, or place it in a fresh biohazard bag inside a graduate container and then we could fill the container with room temperature sterile water, which in my opinion held the cold in and made the process longer.

    Now we may use the medela warmers for thawing also, though I haven't done it yet.
    The whole reason we started looking at warmers was because we heard about several infectious outbreaks around the country. I started looking at units, trialed Penguin and Medela and after much research, thought and this great site, have decided against Medela and chose the Penguin. The reason was because of the high heat (150-170 degrees) and potential airborne illnesses that the Medela could cause. The Penguin has an isolation Therma-Liner thatcompletely isolates potential pathogens found in water. My rep told me that the liners were created based on three decades of FDA driven and proven pharmaceutical manufacturing practices (isolated water jacket). I trialed the units and liners for more than 30 days and not one ever leaked, they were safe, are cost effective (for a medical supply) and protect the bottles and syringesfrom aggressive temperatures. What really got me about the Medela and sealed my decision was when I did some research and found in several different areas the following information: Since most feeding containers (i.e. bottles, syringes, bags) are made of plastics, the low threshold temperature of thermal transduction with water, protects the baby's feedings from potential contamination of plastic extractables and chemicals. According to United States Pharmacopeia (USP), accelerated temperature studies for plastic extractables are released at 120F. Since the Medela unit uses a heater coil and fan that takes in air from the outside (i.e. NICU unit), heats it up and then it is blown directly onto the feeding, the air has to heated to 150-170 degrees before it will start to efficiently warm the bottle. A staff member pointed out to me that the top of the feeding was hotter than the bottom, by a significant difference. Blowing that hot of air on top of a plastic bottle surely could potentially release extractables that we just don't know about yet. The Penguin keeps temperatures well below the 120 degree temperature threshold and helps to define best practice in nutritional warming.

    I love hearing how everyone is handling feedings in their units and learning from everyone.
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    We will be putting in our revised protocol for breastmilk feedings. Once it is a standard of care for our institution and is in a protocol then we are able to make it a charge item. We have done this with our UAC/PICC kits, our biosensors, neolinks/inline suction, disposable ISC probes, things of that natures. We just have to have documentation that it is part of our routine care. Insurance companies often want to see the documentation that it is something that is used in our standards. We also can charge for eggcrates, positioning items, and that such as we have it in our skin protocols and developmental protocols.

    We are a large teaching hospital with up to 60 if pushed.
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    Another local respected unit uses the penguin heaters. The staff in our unit was not given any chance to comment other than when we trialed the Medela warmers. Of course we were thrilled to have ANYTHING vs. nothing. I understand the potential drawbacks of the medela warmers, but given our choices (none), we were excited to get anything at all.
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    Quote from rn/writer
    Can I ask a really dumb question? I'm a postpartum nurse who gets floated to NICU. All I've ever seen used to heat a bottle of breast milk or formula is a large Styrofoam cup of hot water. Yes, there is the possibility of a spill, but that hardly ever happens. The NICU has practical places that are good for placing the cup-and-bottle arrangement that are stable and wouldn't allow damage or a big mess if something did spill.

    It's low tech and much less expensive. No hot spots. The cups are disposable. If the bottle is placed in the cup before baby gets changed and has vitals done, it's ready at just the right time.

    This is how we heat bottles for the fussy ones on postpartum, too, although most just get room temperature milk.

    I'm confused about why such expensive units need to be purchased. This is a serious inquiry, not a joke or a criticism.

    Thanks in advance.
    I agree, we also just use hot water (in one of those pink ice/water buckets). I don't see the point in spending hundreds of dollars for these things.
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    Quote from Bortaz, RN
    I agree, we also just use hot water (in one of those pink ice/water buckets). I don't see the point in spending hundreds of dollars for these things.
    I know the gripe against the foam cups, but the liners for these warmers are also disposable. I wonder how biodegradable they are. Six or more of those a day would certainly add up.

    As for the infection control issues, if the cups are tossed after 24 hrs. and the water level is kept low enough, I don't see that being a problem either. It hasn't been in the NICU where I get floated. I could see using special warmers for the really fragile babies, but for more stable kids and the feeders and growers, they seem like an unnecessary expense.

    I should mention that we have faucets where the water can get really hot. For all but the biggest babies, we transfer the milk (breast or formula) into the little graduated feeder bottles. They heat up nicely in 10-15 minutes and I can't think of a single problem that has come from this low-tech option other than the occasional spill. But, as I said earlier, each crib pod has a good place to set the warming bottle where it is not likely to get jostled, and if it did, it wouldn't do any damage.

    It does sound like the Penguin warmers are a lot better than the Medelas. I'm just for keeping things simple and inexpensive unless there's a compelling reason to do otherwise.
    Bortaz, RN likes this.
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    Our purchase was prompted by an outbreak of Legionairre's in our hot water tanks. We use the warmers to warm sterile water for our micronates too. It is great for refridged formulas and no more water by the bedside to spill on to the keyboards and other things on our counters.

    We used cups and those pink plastic things, but ID wanted us to throw them out once a day since there is a risk of bacterial growth unless you were wiping them with red wipes...who wants to float food in something that had been wiped out with those wipes?

    Like I said, we use it as a charge item and recoup some of the cost.
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    I agree totally with keeping things simple but must say, there is a lot of science behind these things and while I "think" I know a lot about them, it really is impressive to listen to all the research and science that has been put into them. I have a feeling that in no time flat, JCAHO will be looking as mandating everyone have a warmer for standardizing everything, but who knows. I am thrilled we will have the Penguin in our unit.
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    We recently switched to the warmers. We used to use plastic cups with warm water to heat the milk, which I personally never had a problem with, nor ever spilt (which is saying a lot for me, bcause I can be very clumsy). Sure the warmers are fancy, but they don't warm the milk up any faster than the cups of water. We have at least one warmer for every two bed spaces (42 bed unit). Our nutrition department thaws and mixes all of our breatmilk, so defrosting it is not an issue (they only have one, so they still use the cup method mostly). I just wish we would have spent the money on something else... we could really use new computer work stations, because ours are litterally falling apart.
    Last edit by sirI on Aug 27, '12

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