In a devastating medical mix-up, a four-month-old baby in the Schneider Children’s Medical Center in Petah Tikva was accidentally given a bottle containing the breast milk of an HIV carrier. The incident occurred on Saturday, but the source of the milk was only confirmed as an HIV carrier on Monday. The error was first reported by Channel 10 television.
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The baby was supposed to have been given his mother’s pumped breast milk, but a nurse apparently provided the wrong bottle. The baby’s mother noticed that the name on the bottle was not her son’s while feeding him and alerted the hospital staff.
For security reasons, parents do not have access to the refrigerator in which the pumped breast milk is stored.
The hospital, in accordance with procedure, ran tests on both mothers after discovering the mix-up. The tests revealed that the woman whose breast milk the baby drank was an HIV carrier. She was breast-feeding her own baby because she had not been previously diagnosed and was unaware that she was a carrier. (The milk itself was not tested.)
The policy of the U.S. Centers for Disease Control and Preventoin is that HIV-infected women should not breastfeed their infants, while the World Health Organization, based on emerging research, recommends HIV-positive mother's to exclusively breastfeed their babies in combination with antiretroviral treatment.
After consulting experts in infectious diseases, Schneider began giving preventive treatment to the baby who received the potentially virus-carrying milk. The treatment, which resembles that given to medical staff or rape victims who may have been exposed to the virus, will continue for several months and the baby will be tested regularly.
The hospital stressed that “the chances of contracting the virus from a one-time feeding with a carrier’s breast milk are negligible. We don’t know of a single case of infection with the virus after a one-time feeding with an HIV carrier’s breast milk that has been described in the international medical literature.”
The preventive treatment “significantly reduces the chances of contracting the virus, and is particularly effective [when given] soon after the date of exposure,” the hospital added. “This treatment is also given in situations where it’s still impossible to know for sure whether infection has occurred.”
Just a few months ago, Schneider received accreditation from the Joint Commission International. To earn this prestigious international accreditation, a hospital must prove that it meets high standards of quality and patient safety.
The hospital said it “deeply regrets the error and is conducting a comprehensive investigation in order to learn the lessons and prevent a recurrence of this incident. The incident has been reported to the Health Ministry.” The ministry confirmed that it had received the hospital’s report.