1 Survey

Appendix A A.2.3.k–3

National Children’s Study

Breast Milk Collection Instructions

OMB#: 0925:xxxx

Expiration Date: xx/xxx

As part of the National Children’s Study, we are asking you to collect a sample of your breast milk. Please collect this sample as close to ___/___/___ as possible.

You have been provided with everything you will need to collect the sample.

• 3–Sterile absorbent cloths

• Breast pump accessories (breast shields, tubing, valves, membranes, collection bottles)

• 1–Pre-labeled plastic conical tube

• 1–Pre-labeled brown glass bottle

• Freezer packs (Please place freezer packs in the freezer as soon as possible after you receive them.)

• A Breast Milk Data Collection Form

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Important instructions before getting started!

• Make sure to pump enough milk ahead of time so that you have milk to feed your baby around the time of this collection. You may not have enough milk left after this collection to satisfy your baby.

• Do not feed your baby or pump, eat food, or take medication for 2 hours prior to this collection.

• Assemble pump using directions provided with the pump.

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Collection Instructions:

1. Thoroughly wash your hands, rinse, and dry with a clean towel.

2. Wash your breasts and nipples using the cloth provided and warm tap water. This is the area that will attach to the collection funnel of the pump. Gently dry the area with a clean dry cloth.

3. Center the breast shield over the nipple, such that the nipple is inside the opening of the shield (funnel portion of the apparatus).

4. Turn on the pump at minimum suction strength and increase in strength to meet your personal comfort level.

5. Sit back, relax and let the pump do the work. Try and collect as much as you can from both breasts, but you can stop if you reach 3 ounces total.

6. When the milk flow ceases you may turn off the pump. Lean forward and break the suction seal on the breast with a finger.

7. Set the pump bottles down on a flat surface and dry breasts, if needed, with a clean cloth.

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Immediately after collection complete the following steps:

1. Gently mix the milk in the pump collection bottles by swirling the bottles. (Combine the 2 bottles if possible.)

2. Pour the milk to the fill line in the plastic conical tube and immediately pour that volume into the brown glass bottle. Place the cap on the brown glass bottle.

3. Again, pour the milk from the pump collection bottles into the plastic conical tube to the fill line. If you don’t have enough milk to fill to the fill line, this is OK, just fill with what you have. Cap the plastic conical tube.

4. If there is any milk left over in the collection bottles it can be saved for your child.

5. Place the brown bottle and plastic tube into the plastic bag containing the absorbent pad, seal the bag and place it in the freezer.

6. Complete the Breast Milk Data Collection Form.

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Shipping Instructions:

The day after the sample is collected and frozen you should mail it to the NCS Biospecimen Repository. Follow the instructions provided below to mail your sample.

1. Place two frozen cold packs in the bottom of the shipping box then place the frozen breast milk samples on top of the cold packs. Place the remaining two frozen cold packs on top of the samples.

2. Place the completed Breast Milk Data Collection Form into the enclosed plastic bag and put the bag in the shipping box.

3. Seal the box with the strapping tape provided. Put today’s date on the FedEx label and call FedEx for a pick up. The Fed Ex telephone numbers and pick-up times are provided as a separate insert.

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Feel free to call if you have any questions.

[Name and phone numbers]

For Office Use Only

Participant # __ __ __ __ __

Visit #__ __ __ __ __

National Children’s Study

Breast Milk Data Collection Form

As part of the National Children’s Study, we are asking you to provide a breast milk sample.

You have been provided materials for collecting breast milk, including breast pump accessories (breast shields, tubing, valves, membranes, and collection bottles), a pre-labeled plastic conical tube, and a pre-labeled brown glass bottle.

Questions for Breast Milk Collection	Response
1) What is today’s date?	___ ___ /___ ___ / ___ ___ ___ ___
2) What time did you last pump or nurse before collecting your breast milk sample?	___ ___ : ___ ___ □ am □ pm
3) What time did you pump your breast milk sample?	___ ___ : ___ ___ □ am □ pm
4) What time did you place the samples in the freezer?	___ ___ : ___ ___ □ am □ pm
5) Comments/Notes:	_______________________________________ _______________________________________
Please be sure to include this form when shipping the sample to the repository. Thank you for providing this information!
For Repository Use only
Date received: ___ ___/ ___ ___/ ___ ___ ___ __		Condition: □ Frozen □ Thawed
Conical tube volume: ____________ml		Brown glass bottle volume: ________ml