Bloom Pediatrics and Lactation

Families who choose to utilize milk from Bloom Pediatrics and Lactation recognize that in doing so they are stepping outside of the current U.S. medical mainstream and that they take responsibility for that decision. In the interest of protecting all involved – donor, recipient, and Dr. Hughes/Bloom Pediatrics and Lactation – and in keeping with a strong commitment to facilitating recipient’s informed choice, the following Waiver and Release clarifies the scope and nature of this responsibility. Please do not sign this Waiver and Release unless you fully understand and agree to its contents.

By my signature below, I confirm my understanding of and agreement with all of the following:

The American Academy of Pediatrics recommends against direct mother-to-mother milk sharing as an option for infant feeding, citing health risks that include the transmission of serious illnesses. The U.S. Food and Drug Administraton (FDA) has warned about risks for the baby including exposure to infectious diseases, to chemical contaminants, and to some prescription drugs that might be in human milk if the donor has not been adequately screened. In additon, if human milk is not handled and stored properly, it could, like any type of milk, become contaminated and unsafe to drink. The FDA recommends that a mother first consult with a healthcare provider, and if, after the consultaton, the mother decides to receive human milk from another mother, she only use milk from a source that has screened its milk donors and taken other precautions to ensure the safety of its milk. The Academy of Breastfeeding Medicine has a position paper that has helped guide this donation and recipient process, as well as home pasteurization information.

The handling, storage, and sharing of human breast milk carries inherent risks that may result in illness, disease, or death. I am receiving human breast milk that has been voluntarily donated to Bloom Pediatrics and Lactation by donors who have undergone a limited health history and blood screening by Dr. Hughes. Donors have also been instructed in milk handling and storage via the Bloom Pediatrics and Lactation document, "Donor Guidelines for Pumping and Handling". The donated milk itself has not been tested or pasteurized. Further, I have seen the written milk thawing and handling guidelines by Bloom Pediatrics and Lactation. I have read and fully understand the Bloom Pediatrics and Lactation document, “Recipient Guidelines for Milk Handling”. I also have seen the written instructions in the evidence-based process of at home stove-top flash-heat pasteurizaton of breast milk.

While Dr. Hughes/Bloom Pediatrics and Lactation has undertaken the above-described screening and educaton with respect to the safety of human milk, neither Dr.Hughes/Bloom Pediatrics and Lactation nor any of its donors make any warranties or guarantees, expressed or implied, with respect to the wholesomeness, quality, or health characteristics of donated milk. In additon to risks related to disease and transmission, milk composition varies according to individual donor diet and exposure, the age of the donor’s infant, and the duraton of milk storage.

With full acknowledgment of potental risks associated with the handling, storage, and sharing of human breast milk, I, on my own behalf and on behalf of any and all of my children who consume donated milk from Bloom Pediatrics and Lactation, accept all risk and responsibility of using and consuming donated milk and any activity incidental thereof. I also hereby discharge and release Dr. Hughes/Bloom Pediatrics and Lactation and all of its donors both on my own behalf and on behalf of any and all of my children who consume donated milk from Bloom Pediatrics and Lactation, from any and all liability for any personal injury, disease, illness, sickness, adverse health effect or risk, including, but not limited to, risks of property damage or wrongful death that may result from using or consuming donated milk, whether or not caused by the act, omission, negligence, or other fault of Dr. Hughes/Bloom Pediatrics and Lactation or any of its donors. I agree that under no circumstances will I or any third-party, on my own behalf or on behalf of any or all of my children who consume donated milk from Bloom Pediatrics and Lactation, present any claims against Dr. Hughes, Bloom Pediatrics and Lactation, or any of its donors, for using and consuming donated milk or any actvity incidental thereof.

I have read and fully understand the terms of this Waiver and Release. I intend my signature to be a complete and unconditional waiver and release of all liability of Dr. Hughes, Bloom Pediatrics and Lactation, and its donors. I understand that this
Waiver and Release will remain in effect unless revoked in writing.

I hereby agree to the terms of this Waiver and Release by signing freely and voluntarily.