Breast Milk Collection and Storage in the
Neonatal Intensive Care Unit: Nurses
Knowledge, Practice, and Perceived Barriers
Huda Falah Gharaibeh, RN, PhD; Nihaya Al-sheyab, PhD, MsN, RN;
and Shefa Yousef Malkawi, RN, MSN
abstract
Background: Temporary storage of human milk under
appropriate conditions encourages prolonged breast-
feeding.
Purpose: This study aimed to assess neonatal nurses
knowledge and practice, as well as barriers, related to
breast milk collection and storage and to investigate the
association between nurses knowledge and practice and
other variables.
Method: A cross-sectional design was used. Consecu-
tive samplings of 75 nurses were recruited. The questions
were based on a literature review of guidelines for col-
lecting and storing breast milk from various sources, such
as the Centers for Disease Control and Prevention and the
Academy of Breastfeeding Medicine.
Results: Nurses knowledge and practice of breast
milk collection and storage were adequate in general, but
inadequate in relation to issues such as discarding breast
milk, the thawing process, and storage temperatures.
Poor practices related to absence of required equipment
and unit policy. Barriers were increased workload, inap-
propriate milk room (i.e., a small room with uncomfort-
able chairs and no privacy), inactive policy, and inade-
quate time.
Conclusion: Nurses should be orientated to the guide-
lines and a unit policy to enhance evidence-based practice.
J Contin Educ Nurs. 2016;47(12):551-557.
E vidence shows that temporary storage of human
milk under appropriate conditions encourages the
practice of prolonged breastfeeding and allows babies
to obtain the benefits of breast milk (Lawrence, 1999;
Ogundele, 2000). Infants with very low birth weight
The Journal of Continuing Education in Nursing Vol 47, No 12, 2016
(VLBW) (1500 g [3.3 lb] or lower) are not able to be fed
steadily from their mothers because they may have dif-
ficulties including weak, immature, or irregular sucking
and swallowing. For this reason, expressed breast milk
has to be administered in a different way (DallOglio et
al., 2007). Mothers of VLBW infants do not usually pro-
vide sufficient milk to meet the needs of their newborns
because they stop expressing milk or have an insufficient
amount of breast milk (Lau, Hurst, Smith, & Schanler,
2007). Frequent expression, starting in the first 6 hours
after giving birth, is crucial for successful lactation in sit-
uations when mothers are in a different place than their
newborn babies (Ohyama, Watabe, & Hayasaka, 2010).
The benefits associated with breastfeeding underscore
the critical need for the health care system to develop
programs that facilitate increased rates of breastfeeding
among premature babies. Similarly, breastfeeding educa-
tion, frequent support, and follow up from neonatal in-
tensive care unit (NICU) nurses for mothers of preterm
infants have been shown to increase their breastfeeding
rate on discharge, as well as decreasing breastfeeding
problems (Ahmed, 2008).
The method by which breast milk is collected, stored,
and administered to VLBW infants or those born before
Dr. Gharaibeh is Associate Professor and Nursing Faculty, and
Dr. Al-sheyab is Assistant Professor for Child and Adolescent Health,
Maternal-Child Health and Midwifery Department, Jordan Univer-
sity of Science and Technology; Ms. Malkawi is Staff Nurse, Princess
Rahma Hospital, Irbid, Jordan.
The authors have disclosed no potential conflicts of interest, finan-
cial or otherwise.
Address correspondence to Huda Falah Gharaibeh, RN, PhD, Asso-
ciate Professor and Nursing Faculty, Maternal-Child Health and Mid-
wifery Department, Jordan University of Science and Technology, PO
Box 3030, Irbid, Jordan, 22110; e-mail: hudag@just.ed.jo.
Received: November 17, 2015; Accepted: September 2, 2016
doi:10.3928/00220124-20161115-08
551
32 gestational weeks needs to be conducted properly to
preserve the important nutrients in the milk. In addition,
the methods need to avoid contamination by storing breast
milk appropriately for at least limited periods of time in the
NICU (DallOglio et al., 2007; Ogundele, 2000).
Mothers who choose to breastfeed newborn babies
admitted to the NICU should be taught by NICU nurs-
es about the hospital guidelines for storing, freezing, and
thawing expressed milk. Providing careful instructions for
mothers who express milk at home, including labeling and
tracing storage, is a nurses responsibility. Infants in the
NICU are more likely to receive the maximum benefits of
breast milk if the process is conducted appropriately. The
collection and storage of breast milk in the NICU is a nurs-
ing procedure that mothers participate in; therefore, NICU
nurses and mothers should collaborate to optimize expres-
sion, safe collection, storage, and use of mothers own milk.
Assessing NICU nurses knowledge and practice of
breast milk collection and storage in a country such as
Jordan, with limited access to health care facilities, is
critical. Information from the current study will provide
baseline data to support appropriate interventions to es-
tablish breast milk expression, collection, and storing for
NICU infants, with the goal of increasing the percent-
age of breast milk feeding among NICU babies (Meier,
Engstrom, Patel, Jegier, & Bruns, 2010; Sisk, Lovelady,
Dillard, Gruber, & OShea, 2007). Nurses play a valu-
able role in increasing awareness of the benefits of breast
milk, as well as in educating mothers about the impor-
tance of early and regular pumping. Limited literature
was found about nurses knowledge and practice related
to breast milk collection and storage in NICUs, as most
of the studies focused on their knowledge and practice
related to breastfeeding in general.
Therefore, this study aims to assess Jordanian neo-
natal nurses knowledge and practice, as well as barri-
ers, related to breast milk collection and storage, and to
investigate the association between nurses knowledge
and practice in Jordanian hospitals to reduce the gaps
between knowledge and practice.
METHOD
A descriptive cross-sectional design was used in this
study. The target population of the study was all NICU
nurses employed in Ministry of Health (MOH) hospi-
tals (six hospitals) in Northern Jordan. A consecutive
sample of 77 NICU nurses was used to recruit partici-
pants for the study.
DATA COLLECTION PROCEDURE
The permission to conduct this study was obtained
from the Ministry of Health, the university institutional
552
review board, and each hospital authority. The principle
investigator (S.Y.M.) met the head nurse and nurses in
each selected NICU and explained the purpose of the
study. The study population consisted of 77 NICU nurses
who work at the six hospitals. Each NICU nurse met the
inclusion criteria, was invited to participate in the study,
and received verbal and written information about the
nature and purposes of the study. Also, participants were
informed that the questionnaire is self-administered and
were notified of their rights not to participate and to with-
draw from the study at any time. Participants were asked
to sign a consent form. The information sheet and consent
form are presented in the first paper of the questionnaire.
The collected data were stored in a locked cabinet with
access limited to the researchers.
INSTRUMENT
A questionnaire was developed by the researchers
to determine knowledge and practices surrounding the
collection, storage, and thawing of breast milk among
NICU nursing staff. The questions were developed
based on a literature review of the guidelines for col-
lecting, storing, and thawing breast milk from the Cen-
ters for Disease Control and Prevention (2010), based
on guidelines from the Academy of Breastfeeding Med-
icine (2010), and storing and handling human milk in
hospitals (Italian Association of Human Milk Banks
[Associazione Italiana Banche del Latte Umano Do-
nato] et al., 2010; Hartmann, Pang, Keil, Hartmann, &
Simmer, 2007; Nutt, 2006). In addition, other available
sources, such as the Italian and Australian guidelines
for breast milk collection and storage, were reviewed.
The questionnaire comprised five sections: sociode-
mographic characteristics, NICU nurses knowledge
of breast milk collection and storage, practice, per-
ceived workplace environment, and perceived barri-
ers. The knowledge section consisted of 24 items rated
on a 4-point Likert scale (4 = strongly agree, 3 = agree,
2 = disagree, 1 = strongly disagree). Some of the items
were reverse coded as appropriate to ensure correct
data entry. The Practice section was designed to deter-
mine NICU nurses practice of breast milk collection
and storage and consisted of 12 questions with a 4-point
Likert scale (4 = always, 3 = very often, 2 = sometimes,
1 = never). Correctly stated, knowledge and practice
items with a mean score of 3 or more were considered
as adequate knowledge and good practice as the nurses
agree or strongly agree about correct statements; wrong-
ly stated knowledge items and practice with a mean score
of 3 or more were considered as inadequate knowledge
and poor practice as the nurses agree or strongly agree
about wrong statements.
Copyright SLACK Incorporated
 Perceived workplace environment consisted of six
yes-or-no questions asking about the suitability of the TABLE 1
workplace for nurses and mothers to properly practice SOCIODEMOGRAPHIC CHARACTERISTICS OF
breast milk collection and storage. The last section asked PARTICIPANTS (N = 75)
about perceived barriers to adhering to their units policy Characteristic n (%)
about breast milk collection and storage, and consisted
Age (years)
of 11 yes-or-no questions.
,25 7 (9.3)
VALIDITY AND RELIABILITY 26 to 35 50 (66.7)
Content validity was evaluated by a panel of experts >36 18 (24)
consisting of three university professors to validate the Educational level
content of the questionnaire. The questionnaire was first
Diploma 24 (32)
developed in English, then translated into Arabic, and
Bachelor 44 (58.7)
finally back-translated to English by three panels of ex-
perts from the Nursing Faculty at Jordan University of Postgraduate 7 (9.3)
Science and Technology. Minor suggestions concerning Experience (years)
the wording of a few sentences were recommended. The 1-5 15 (20)
changes enhanced the face validity of the instrument. 6-10 34 (45.3)
The instrument was pilot tested with six NICU nurses
.10 26 (34.7)
who met the inclusion criteria of the main study. Pilot
study results showed that the instrument was easy to ad-
minister, was clear to read, and took an average of 10 to
15 minutes to be completed. ly stated items were: Microwave oven can be used
for thawing or warming breast milk (mean = 3.62);
STATISTICAL ANALYSIS Thawed breast milk can be refrozen again (mean =
The data were analyzed using SPSS for Windows 3.49); and Frozen breast milk should be thawed by put-
version 20 software. The quantitative data obtained from ting the bag of milk in boiling water (mean = 3.37; Table
NICU nurses were analyzed using descriptive statistics, 2).
including percentages, frequencies, means, and standard The highest mean scores concerned nurses practice as
deviations for each study variable. A multivariate analy- reported in the following statements: I use a microwave
sis using a general linear model was performed to assess oven for heating breast milk (mean = 3.90), and I thaw
the association between sociodemographic and related breast milk by putting the breast milk bottle in boiling
variables of participants and their knowledge and prac- water (mean = 3.78). For example, the item My prac-
tice level. A p value of less than .05 was considered sta- tices about breast milk collection and storage are from
tistically significant. the units policy has a mean score of 2.40, whereas the
item I advise mothers to discard breast milk if the infant
RESULTS is NPO [given nothing by mouth] for a long period has
The study population consisted of 77 NICU nurses a mean score of 2.37.
who work at the six hospitals and were invited to par- Results also revealed that nurses performance re-
ticipate in the study. A total of 75 completed the ques- garding teaching mothers was not adequate for I
tionnaire, giving a response rate of 97.2%. The mean teach mothers about the expired time of breast milk
age of the nurses was 31 years (SD = 4.6 years). More in different temperatures, with a mean score of 2.61
than half (58.7%, n = 44) had a bachelors degree in (Table 3).
nursing, and 45.3% (n = 34) had 6 to 10 years of experi- The results regarding workplace environment showed
ence (Table 1). that almost all (94.7%) of the NICU nurses indicated that
Item analysis showed the following inadequate knowl- mothers were allowed to collect and store breast milk in
edge for correctly stated items: Breast milk can be stored the unit, and that there is a special room for collecting
at room temperature for up to 6 hours (mean = 2.70); the milk. In relation to unit policy, two thirds (66.7%)
Breast milk can be stored in regenerator for 2 to 5 days of nurses reported there is no written policy for breast
(mean = 2.84); and Frozen breast milk can be thawed by milk collection and storage, and almost half (46.7%) re-
putting it in the refrigerator overnight (mean = 2.49). ported that there is no special refrigerator to store breast
Items showing inadequate knowledge for wrong- milk in the unit. The majority (85.3%) of nurses indi-

The Journal of Continuing Education in Nursing Vol 47, No 12, 2016 553
 TABLE 2

DESCRIPTIVE ANALYSIS OF KNOWLEDGE STATEMENTS (N = 75)

Statement Meana SD
Mother should wash her hands and breasts before collecting milk. 3.96 0.197
Milk containers should made from glass or hard plastic. 3.65 0.479
Containers used to collect and store breast milk should be clean and sterile. 3.96 0.197
A space should be left in the expressed milk container before freezing for milk expansion. 3.48 0.600
All used equipment should be sterilized by putting in boiled water for 10 minutes. 3.61 0.517
A label with the mothers name, time, and date should be put on the milk container. 3.86 0.342
Breast milk should be directly stored and not left at room temperature. 3.78 0.473
Breast milk amount stored in the container should be equal to the baby feed. 3.54 0.722
Breast milk should be stored in the coldest part in the refrigerator. 3.65 0.581
The oldest stored breast milk should be used first. 3.81 0.425
Refrigerator temperature used to store breast milk should be 4C. 3.24 0.713
Freezer temperature used to store breast milk should be 18C. 3.21 0.776
Breast milk can be stored in room temperature with 25C up to 6 hours. (poor knowledge) 2.70 0.911
Breast milk can be stored in the back of the main body of refrigerator for 2 to 5 days. (poor knowledge) 2.84 0.901
Breast milk can be stored toward the back of the freezer section of the refrigerator with separate doors for 3 months. 3.21 0.842
Breast milk can be stored on the refrigerator door. (poor knowledge) 2.80 0.854
Microwave oven could be used for thawing or warming breast milk. (poor knowledge) 3.62 0.513
Frozen breast milk can be thawed by being put in refrigerator overnight. (poor knowledge) 2.49 0.920
Frozen breast milk can be thawed by being put in warm water. 3.00 0.900
Frozen breast milk should thawed by putting the bag of milk in boiling water. (poor knowledge) 3.37 0.652
The rest of baby feed can be reused in the next feed without considerations. 2.84 0.913
Thawed breast milk could be refrozen again. (poor knowledge) 3.49 0.623
Mother can express her breast milk either by hand or manual technique. Manual technique includes using some 3.30 0.592
aid of expressing the milk (e.g., a breast pump).
Mother should discard her breast milk if the baby was fasting for long period of time. (poor knowledge) 2.40 1.102
a
Items were rated on a 4-point Likert scale (4 = strongly agree, 3 = agree, 2 = disagree, 1 = strongly disagree).

cated that no brochures explaining the correct technique
or appropriate temperatures to collect and store breast
milk are provided to mothers. Approximately 74.7% of
participants claimed that mothers are not provided with
the necessary equipment for breast milk expression, such
as pumps (Table 4).
Analysis of variance (ANOVA) between nurs-
es knowledge and sociodemographic variables us-
ing post hoc comparison tests indicated that older
nurses (>36 years) have significantly more adequate
knowledge than the other age groups (p = .001). The
mean score for group 1 (<25 years old; mean = 75.00,
SD = 2.08) was significantly different from group 2
(26-35 years old; mean = 79.28, SD = 5.56) and group
3 (>36 years old; mean = 83.88, SD = 4.33). Also,
there was a statistically significant difference between
nurses knowledge and hospital location (p = .001) and
a significant knowledge difference between nurses at
different hospitals: nurses at Hospital B showed ade-
quate knowledge (mean = 84.77, SD = 5.56) and nurses
at Hospital D showed inadequate knowledge (mean =
74.10, SD = 3.90), compared with nurses at other hos-
pitals (Table 5).
Regarding perceived barriers that prevent nurses ad-
hering to unit policy regarding breast milk collection and
storage, the findings revealed that the nurses claimed that
there is either no unit policy or an inactive unit policy;
workloads, inappropriate milk room (i.e., a small room
with uncomfortable chairs and no privacy), and time
were the main barriers.

554 Copyright SLACK Incorporated

 TABLE 3

DESCRIPTIVE ANALYSIS OF PRACTICE STATEMENTS (N = 75)

Statement Meana SD
I teach mothers about the importance of collecting and storing breast milk. 3.25 0.77
I teach mothers about the right practice for collecting and storing breast milk. 3.02 0.73
My practices about breast milk collection and storage are from the unit policy. (poor practice) 2.40 1.21
I advise mothers to wash their hands before collecting breast milk. 3.88 0.36
I advise mothers to wash their breasts before collecting breast milk each feed. 3.74 0.54
I advise mothers to discard breast milk if the infant is NPO [given nothing by mouth] for long period. (poor practice) 2.37 1.29
I advise mothers to early express breast milk after birth. 3.22 0.84
I support mothers to enhance breastfeeding. 3.73 0.60
I use a microwave oven to warm breast milk. (poor practice) 3.90 0.44
I thaw breast milk by putting the breast milk bottle in boiling water. 2.40 1.22
I teach mothers about the expired time of breast milk in different temperatures. (poor practice) 2.61 0.89
I thaw breast milk by putting the breast milk bottle in warm water. 3.78 0.70
a
Items were rated on a 4-point Likert scale (4 = always, 3 = very often, 2 = sometimes, 1 = never).

DISCUSSION regular workshops, effective and available brochures,

In this sample of NICU nurses, there was general
agreement about the importance of their role in pro-
moting breast milk collection, storage, and supply.
NICU Nurses Knowledge
Although the majority of respondents from the six
selected hospitals had adequate knowledge about the
overall process of breast milk collection, a knowledge
deficit was found in the important domains of breast
milk collection and storage. Nurses were knowledgeable
about hand and breast washing, as well as cleaning and
the sterilization of equipment, that can enhance mothers
engagement in safe preparation and storage techniques.
However, they were found to have an inadequate knowl-
edge level regarding some important issues concerning
expiry date of breast milk stored at different tempera-
tures, the thawing process, and freezing the milk rather
than discarding it if the premature is not given anything
by mouth for a long period of time. This inadequate level
of knowledge for these items indicated that NICU nurs-
es do not adhere to the current guidelines, even though
there is a detailed policy available to all nurses in each
selected NICU hospital, explaining the guidelines for
collecting, storing, and thawing breast milk. In the cur-
rent study, it was found that about two thirds of NICU
nurses did not know the unit policy for collecting, stor-
ing, and thawing breast milk and had not received any
information about it. It is therefore suggested to provide
continuing education, appropriate policy orientation,
and learning activities about the units policy and guide-
lines. Also, unavailability of a specially designated re-
frigerator, breast pumps, and special containers for milk
storage may have minimized the knowledge-seeking
behaviors about breast milk collection and storage in
NICUs. Nurses need to know the importance of family
engagement in the process of milk collection and storage.
NICU Nurses Practice and Perceived Barriers
It is also necessary to improve nurses performance
regarding milk thawing, refrigerating, and freezing. Sim-
ilarly, one study (McLauglin, Fraser, Young, & Keogh,
2011) of pediatric nurses knowledge related to breast-
feeding hospitalized infants, policy and guideline aware-
ness, and attitudes to breastfeeding revealed that partici-
pants demonstrated positive breastfeeding attitudes and
excellent general knowledge, but there was insufficient
knowledge relating to specific outcomes, such as main-
tenance of milk supply, expressing milk, and local, na-
tional, and international policies, protocols, and recom-
mendations.
It was found in this study that NICU nurses are not
aware of the importance of breast milk expression, col-
lection and storage for later use; for example, the state-
ment [a] mother should discard her breast milk if her
baby was NPO. This finding is alarming given the
importance of breast milk expression and collection to
maintain breast milk synthesis when the infant is unable
to breastfeed directly from his mother. Similarly, Spatz

The Journal of Continuing Education in Nursing Vol 47, No 12, 2016 555
 TABLE 4

PERCEIVED WORK PLACE ENVIRONMENT STATEMENTS (N = 75)

No. Responding No. Responding
Statement Yes (%) No (%)
It is allowed for mothers to collect and store breast milk in the unit. 71 (94.7) 4 (5.3)
There is a special room for collecting breast milk. 71 (94.7) 4 (5.3)
Mothers are given needed equipment for breast milk expression. 19 (25.3) 56 (74.7)
There is a special refrigerator to store breast milk in the unit. 40 (53.3) 35 (46.7)
There is no written policy for collecting and storing breast milk. 25 (33.3) 50 (66.7)
Mothers are given a brochures explaining the right technique to collect and store breast milk. 11 (14.7) 64 (85.3)

TABLE 5

ONE-WAY ANALYSIS OF VARIANCE BETWEEN NURSES KNOWLEDGE AND SOCIODEMOGRAPHIC VARIABLES

(N = 75)
Sociodemographical Variable Mean (SD) p Value
Age (years) .001**
Group 1, <25 75.00 (2.08)
Group 2, 26 to 35 79.28 (5.56)
Group 3, > 36 83.88 (4.33)
Educational level .180
Diploma degree 79.7 (4.61)
Bachelor degree 79.5 (5.01)
Postgraduate degree 83.0 (10.46)
Experience (years) .299
1 to 5 79.6 (7.00)
6 to 10 79.0 (4.50)
.10 81.3 (6.00)
Hospital .001**
Hospital A 80.47 (5.44)
Hospital B 84.77(5.56)
Hospital C 79.60 (3.86)
Hospital D 74.10 (3.90)
Hospital E 78.00 (3.80)
Hospital F 82.40 (5.22)
** p < .05.

(2005) reported that mothers breast feeding should be
as frequent as the infants normal feeding times to main-
tain breast milk production. Also, nurses who work with
families with children are responsible for a great deal of
patient education and can affect womens decisions to
initiate and continue breastfeeding. In addition, nurses
perform the thawing process poorly, as they use the mi-
crowave or boiled water to thaw the frozen breast milk;
this reflects the need for providing appropriate health
education about the expired time of breast milk at differ-
ent temperatures. These practices could pose a potential
threat to patient safety; therefore, this might be related
to their inadequate knowledge or unawareness of their
role as a health educator. This reflects an urgent need

556 Copyright SLACK Incorporated

for NICUs to set goals for breastfeeding promotion and
audits of documentation of initiation and frequency of
breast milk supply. Another study revealed that barriers
to best practices in breastfeeding initiation were hospital
lactation policies, nurses limited education in breast-
feeding initiation, and high rates of surgical delivery
(Weddig, Baker, & Auld, 2011).
Limitations
Limitations existed in this study, such as the small
sample size and the location of the study, which is only
the northern part of Jordan. The sample size was all 77
NICU nurses employed in all hospitals that provide a
NICU in northern Jordan. This size limits the research-
ers to conduct factor analysis to the survey instrument.
RECOMMENDATIONS
An urgent need exists among the study sample for the
development and implementation of effective strategies
to disseminate changes and activate unit policy, proto-
cols, and recommendations to improve nurses knowl-
edge and practice to support breast milk supply among
sick and hospitalized neonates. There is a possible gen-
eralization of the benefit of assessing nurses knowledge
in other sites and settings, as well as countries.
IMPLICATIONS FOR NURSING AND HEALTH POLICY
This study has several implications for health care
providers and policy makers to enhance breast milk
collection, storage, and thawing policies and proce-
dures.
Unit managers should review and update their policies
regarding family engagement in breast milk collection
for instance, increasing visiting hours for breastfeeding
mothers. Hospital administrators can benefit from the
findings of this study by activating and enhancing access
to policies that promote best practice as the unit policy
as the primary recourse for NICU nurses.
The implications of conducting this descriptive study
are an identified need to improve and enhance clinical
nursing practice through education or quality improve-
ment initiatives to enhance knowledge and beliefs about
breastfeeding premature infants and to improve work-
place conditions to be more supportive of breast milk
expression and storage. This study provides an opportu-
nity to develop an action plan for increasing knowledge,
influencing attitudes and beliefs, budgeting for supplies
and equipment, and possibly measuring the effectiveness
The Journal of Continuing Education in Nursing Vol 47, No 12, 2016
of the interventions. An opportunity also exists to mea-
sure percent of infants breastfeeding within 72 hours and
at the time of discharge.
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