Thoughts on warming milk in the NICU

babyNP., APRN · Nov 17, 2011

Yikes! i had no idea the liners were that expensive! You're supposed to change them out qfeed at my facility--the penguin ones.

I like them okay, no real complaints.

Curious why you need liners for the medela ones if it's waterless? How much more expensive are they?

It never ceases to amaze me how much $$ there is in health care.

jayhawkfan · Nov 17, 2011

If I am not mistaken (I am at home now without my notes in front of me) but the Penguin liners would save me approximately $2 per liner over Medela. I think it's like $1.10 versus $3.00. Need the liner in Medela to help keep unit clean since it deals with liquid. Both Medela and Penguin liners are single patient use.

I'm leaning toward the Penguin the more I read about the scientific based evidence behind it and it really is the most reliable in terms of heating, avoiding hot spots etc...I also like the vibration aspect to it. Keeps all the good lipids etc..within the mixture, especially when going from frozen to thaw to warm.

A colleague just emailed and said that the Medela isn't compatible with all makes and models of bottles (i.e. Milk bank glass bottles) and she said they have used glass bottles in their Penguins before.

Being such a huge expenditure I just need to make the right choice.

gibson0726 · Nov 17, 2011

We are currently trialing the Penguin warmers on our unit. The rep who did the in-service told us that the liners can be used for a whole shift - up to 12 hours. She said they recently changed this from q feed changing. I wish they were good for 24 hours, as I feel very guilty throwing away so much plastic.

NicuGal, MSN, RN · Nov 17, 2011

We are trialing the Penguins and have had no problems with them...and we will have to go with them because of cost (we are low bid). We will make the liners a charge item per our purchasing. We use one liner per shift.

jayhawkfan · Nov 20, 2011

We are trialing the Penguins and have had no problems with them...and we will have to go with them because of cost (we are low bid). We will make the liners a charge item per our purchasing. We use one liner per shift.

I am now 100% convinced that the Penguin is the right choice for babies. I don't trust the Medela unit at all. All the research I have put into this has me wanting nothing else and my staff seems pleased. Now I do have a question, I was told we can't charge for liners because it's not a "standard" thing insurance pays for. I would love to know how you are doing it through purchasing. Are you part of a big health system? How many beds do you have? I would love to make this a charge item because then I could purchase more Penguins (ideally I would love to have 1 for every two beds but I can't afford that). Would love insight so I can share with my purchasing department.

umcRN, BSN, RN · Nov 21, 2011

we use penguins, can't tell you how they're charged though. We have 56 beds and every patient has their own warmer, we change the liners q shift.

rn/writer, RN · Nov 21, 2011

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.

umcRN, BSN, RN · Nov 21, 2011

I supposed because we have large quantities of frozen milk (since many NICU babies don't eat right away) and that probably takes longer to defrost in just a cup & water, plus once thawed you only have 24 hours to use it so you can't really take a bunch of bottles out of the freezer and stick them in the fridge...just my thoughts

plus at my hospital if you waited around for the water to get hot the kid might never eat! (I sometimes heat up bath water in the penguin warmer because it's seriously that bad from the tap to get hot water)

TiffyRN, BSN, PhD · Nov 21, 2011

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

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.

jayhawkfan · Nov 21, 2011

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.

jayhawkfan · Nov 21, 2011

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 120°F. 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. :)