1. Donor Milk Use in the NICU: Costs and Benefits Susan Keogh, RNC-NIC, MSN, CNML November 16, 2017

2. Objectives: At the end of this presentation, viewers will be able to discuss the following:
Benefits of breast milk for premature infants vs formula
Cost analysis benefit of exclusive donor milk use vs formula in premature infants
Benefits of adopting statewide guidelines surrounding donor milk use for premature infants in New Mexico

3. Benefits of donor milk for premature infants vs formula
Immune Benefits
Neurodevelopmental Outcomes
GI Benefits
Improved absorption & peristalsis
Lower incidence of infection
Lower incidence of necrotizing enterocolitis (NEC)
Best outcomes are achieved with exclusive human milk diets for premature infants
Nutritional – 30% Casein, 70% whey makes this easier to digest
Whey promotes gastric emptying – better for peristalsis in immature gut
Oligosaccharides prevent bacterial attachment to intestinal mucosa – decreases incidence of systemic Infections and NEC
Infection – infants fed predominantly human milk have significantly decreased rates of late onset sepsis, NEC, and shorter hospital stays
Lower incidence of NEC: Riley Childrens Hospital – 2014, 642 infants, observational study, compared 2.5 years of VLBW infants receiving EHM diet (including donor milk) with previous 6.5 years of infants receiving bovine based products – significant decrease in NEC with those on EHM
Neurodevelopmental outcome of preterm infants is improved by the feeding with human milk:
Long-term studies at 8 years of age through adolescence suggest that intelligence test results, white matter and total brain volumes are greater in subjects who had received human milk as infants in the NICU.
Extremely preterm infants who receive the greatest proportion of human milk in the NICU had significantly greater scores for mental, motor, and behavior ratings at ages 18 months and 30 months. These data remain significant after adjustment for confounding factors, such as maternal age, education, marital status, race, and infant morbidities.
A meta-analysis of 20 studies indicated that LBW infants had greater benefits in cognitive development from being fed human milk (n = 1294) compared to those fed formula (n = 751).[

4. Percentage of infants discharged on any amount of breast milk, <1500 g (VLBW) infants vs all infants
Over time, the percentage of infants being discharged on at least some breast milk in NICUs has slowly increased. Going home on breast milk means the baby almost certainly received some breast milk during their stay in the NICU.

5. Incidence of NEC in the NICU, 2002-2016
Feb 2012: AAP recommends use of donor milk in NICUs to enhance outcomes when mother’s milk is unavailable.
As you can see, incidence of NEC has slowly declined over the same period. This would suggest that human milk may have an influence on incidence of NEC. Studies were needed to confirm this.

6. Relationship between necrotizing enterocolitis (NEC) and neurodevelopmental outcomes
Early Intervention Group:
Studies to date suggest that severe or surgical NEC – at least - is a significant risk factor for early childhood neurodevelopmental impairment in extremely premature infants
Shah D, et. al. (J Pediatrics 2008): Infants with NEC and sepsis/NEC had higher rates of white matter abnormalities on near term MRI, and lower Bayley II scores at 2 years
Hintz, S. (2010): Infants with surgical NEC had significantly lower Bayley II scores at months, higher rates of cerebral palsy and growth failure
Later outcomes:
Majority of neurodevelopmental outcome studies follow only to very early childhood; Some follow-up studies of extremely premature infants at later childhood raise concerns:
Mikkola (Pediatrics, 2005): Perforated NEC associated with cognitive impairment at 5 years
Neubauer (Eur J Pediatr, 2007): Bowel perforation and/or NEC associated with major impairment at school age
These studies all show that babies who get NEC, especially surgical NEC, are at extreme high risk for much worse long term outcomes. A study by Hintz showed that up to 2/3 of all babies with surgical NEC ended up with major disability, such as CP, MR, blindness, deafness, autism, and much higher rates of ADHD, ADD, ODD, learning disabilities, etc. than the general population (up to 90%).

7. Cost analysis benefit of exclusive donor milk use vs formula in premature infants
2006: Meta-analysis looked at benefits of donor milk use in premature infants – found donor milk is beneficial for these kids, resulting in shorter hospital stays related to decreased acuity
Ganapathy et al (2012): Large study in California; compared cost-effectiveness of exclusive donor milk use to any use of bovine products, as well as costs for medical and surgical NEC
Incremental costs of NEC ranged from $50K (medical NEC) to $198K, and up to $680K (surgical NEC)
Hospital stays shortened by average of 4 days if infant did not get NEC
Conclusion: Compared with feeding extremely premature infants with mother’s milk fortified with bovine milk-based supplements, a 100% human milk-based diet that includes mother’s milk fortified with donor human milk- based HMF may result in potential net savings on medical care resources by preventing NEC.
Conclusion: Use of an exclusive human milk diet is best way to decrease incidence of NEC.
So why don’t we just ask mothers to pump more? Why do we need donor milk?

8. Cost analysis benefit of exclusive donor milk use vs
Cost analysis benefit of exclusive donor milk use vs. formula in premature infants
Carroll & Hermann (2013): Retrospective study looked at mean costs of donor milk use for preterm infants during NICU hospital stay
Conclusions:
Most NICU mothers (72%) of very preterm infants were unable to provide all of the milk necessary for an exclusive human milk (EHM) diet, especially in the first few days after birth
Only a few infants (15%) received only donor human milk (DHM).
The cost of DHM per NICU infant ranged from $27 to $590
ml/kg day through 33 weeks PMA
Based on donor milk cost of $4/ounce
The cost of DHM per NICU infant ranged from $27 to $590 and was influenced by the mother’s willingness or ability to provide human milk.
The cost of preventing NEC is relatively low.

9. Cost analysis benefit of exclusive donor milk use vs
Cost analysis benefit of exclusive donor milk use vs. formula in premature infants
Rush University Med Center (2015): Evaluated the cost of NEC related to exposure to human milk feedings to determine difference in NICU hospital costs with and without NEC
291 VLBW infants from
Reviewed incidence of NEC, hospital costs
Average hospital cost $43,818 higher with NEC
Average hospital cost decreased by $9559 for babies who received human milk during first 14 days, and $534/day for each ml/kg/day of human milk thereafter
This study clearly shows the cost savings from preventing NEC is very high when compared to the relatively low cost of donor milk

10. Cost analysis benefit of exclusive human milk use vs
Cost analysis benefit of exclusive human milk use vs. formula in premature infants
Randall Children’s Hospital (2014): Evaluated cost of using EHM diet, including use of donor milk, in infants below 1500 grams at birth
Savings of $416K per 100 high-risk infants for surgical NEC
Cost savings comparison of NEC was $38K for medical NEC
Conclusion: EHM lowered the incidence of NEC compared with preterm formula; DHM diet in very low birth weight infants appears to be cost effective

11. Cost analysis benefit of exclusive donor milk use vs
Cost analysis benefit of exclusive donor milk use vs. formula in premature infants
Lovelace Women’s Hospital (2017): Compared difference in costs related to NEC before and after introduction of exclusive human milk diet in premature infants
VLBW and high-risk infants received days exclusive human milk diet from birth, including use of donor milk in the majority of these infants
Actual costs incurred from treating infants for NEC, per year (low estimate):
2012: 147 net additional hospital days, $1.8M
2013: 141 net additional hospital days, $1.7M
2014: 154 net additional hospital days, $2.5M
October 2015: Exclusive human milk diet introduced in infants with birth weight <1500 g
2015: 63 net additional hospital days, $1.0M
2016: 31 net additional hospital days, $613K
Conclusion: Use of donor milk resulted in overall lower hospital costs and shorter hospital stays

12. Conclusion
Use of donor milk in New Mexico will decrease hospital costs and improve long term outcomes.
Most importantly, widespread adoption of DHM will decrease long-term costs to the state stemming from special services required for infants with major disability (commonly associated with CP and low NDI scores)

13. New Mexico Breast Feeding Task Force Supports the use of donor milk in New Mexico NICUs How can you help? Call your state representative Speak to our state healthcare insurance agencies Get the word out in the community Thank you for helping our Infants!

14. References
American Academy of Pediatrics (2012). Breastfeeding and use of human milk. Pediatrics, (129),
American Academy of Pediatrics (2012, February). Policy statement: Breastfeeding and the use of human milk. Retrieved Oct 1, 2017 from the AAP website: full.pdf
Anderson JW, Johnstone BM, Remley DT. (1999). Breastfeeding and cognitive development: A meta-analysis. American Journal of Clinical Nutrition (70),
Carroll, K. & Hermann, K (2013). The Cost of Using Donor Human Milk in the NICU to Achieve Exclusively Human Milk Feeding Through 32 Weeks Postmenstrual Age. Breastfeeding Medicine, (8)3,
DeSilva A., et al (2004). Does human milk reduce infection rates in preterm infants? A systematic review. Arch Dis Child Fetal Neonatal Ed (89), F
Ganapathy, V. et al (2012). Costs of Necrotizing Enterocolitis and Cost-Effectiveness of Exclusively Human Milk-Based Products in Feeding Extremely Premature Infants. Breastfeeding Medicine, (7)1,
Hermann, K., & Carroll, K. (2014). An exclusively human milk diet reduces necrotizing enterocolitis. Breastfeeding Medicine, (9)4,

15. References
Hintz, S (2010). Neurodevelopmental outcomes of preterm infants after necrotizing enterocolitis. Presented at the Vermont Oxford Network Annual Quality Congress, December Huston et al (2014). Decreasing Necrotizing Enterocolitis and Gastrointestinal Bleeding in the Neonatal Intensive Care Unit. ICAN,(6)2, Hylander MA, Strobino DM, Dhanireddy R. (1998). Human milk feedings and infection among very low birth weight infants Pediatrics (102), e38. Retrieved Oct 1, 2017, from . Jakobsson I, Lindberg T, & Benediktsson B. (1985). Dietary bovine α-lactoglobulin is transferred to human milk. Acta Paediatric Scand (74), Johnson et al. (2015). Cost Savings of Human Milk as a Strategy to Reduce the Incidence of Necrotizing Enterocolitis in Very Low Birth Weight Infants. Neonatology, (107), Lucas A, Cole TJ. (1990). Breast milk and neonatal necrotising enterocolitis. Lancet (336), Lucas A, Morley R, Cole TJ, Lister G, Leeson-Payne C. (1992). Breast milk and subsequent intelligence quotient in children born preterm. Lancet (339),

16. References
Muller G, Bernsau I, Muller W, Weissbarth-Reidel E, Natzchka J. (1986). Cow milk protein antigens and antibodies in serum of premature infants during the first 10 days of life. Journal of Pediatrics (109), Pinelli J, Saigal S, Atkinson SA. (2003). Effect of breastmilk consumption on neurodevelopmental outcomes at 6 and 12 months of age in VLBW infants. Advances in Neonatal Care (3), Quigley, M. & McGuire, W. (2014). Formula versus donor breast milk for feeding preterm or low birth weight infants. Retrieved October 1st, 2017 from the Cochrane Neonatal Reviews website: Schanler, R. (2007). Evaluation of the evidence to support current recommendations to meet the needs of premature inafnts: The role of human milk. The American Journal of Clinical Nutrition (85), 625S-628S. Shah D, et. al. (2008). Postnatal sepsis, necrotizing enterocolitis, and the critical role of systemic inflammation in white matter injury in premature infants. .Journal of Pediatrics (153), Sheard NF, Walker WA. (1988). The role of breast milk in the development of the gastrointestinal tract. Nutrition Review (46), 1-8. Vohr, B., et al. (2006). Beneficial effects of breast milk in the NICU on the developmental outcome of ELBW infants at 18 months of age. Pediatrics (118),