What can we do to improve health outcomes and reduce costs for very low birth weight (VLBW, birth weight (BW) < 1500g) infants, who frequently have very long stays in the neonatal intensive care unit (NICU)?
These infants are more susceptible to morbidities, including late onset sepsis, necrotizing enterocolitis (NEC), chronic lung disease and severe retinopathy of prematurity. Preventing an infant from acquiring one or more of these morbidities thereby improves outcomes, reduces the NICU length of stay and ultimately decreases costs. One safe, effective and low cost strategy to reduce the prevalence of these morbidities is the use of human milk feedings during the NICU hospitalization. Both the amount of human milk feedings and the critical time periods in which human milk is fed during the initial NICU hospitalization are important. The amount or dose of human milk can be measured in various ways, including the daily dose of human milk (ml/kg/day), the percentage of enteral feedings consisting of human milk and simply whether feedings were entirely human milk or not.1-3 The critical time periods for receiving human milk also vary for preventing different morbidities, and may include days 1-14 post-birth, days 1-28 post-birth or the entire NICU stay.1-3
Our research team at Rush University Medical Center is conducting a series of analyses to quantify the cost savings associated with reducing the prevalence of these morbidities through human milk feedings. The first two analyses that have been published focus on human milk feedings, the prevention of late onset sepsis and NEC, and the associated cost savings.
In a study of 175 infants from a prospective cohort study of VLBW infants admitted to Rush University Medical Center between 2008 and 2010, we evaluated the incidence of late onset sepsis and cost of the initial NICU hospitalization for three human milk dose categories calculated for days 1-28 post-birth: <25 ml/kg/day of human milk, 25-49.99 ml/kg/day and ≥ 50 ml/kg/day of human milk.2 We found that both the proportion of infants acquiring sepsis and NICU hospitalization costs decreased as average daily dose of human milk during the first 28 days of life increased (Figure 1). The costs for infants in the lowest human milk dose category (<25 ml/kg/day) had significantly higher NICU costs than infants receiving higher doses of human milk. Cost were 26.7% higher for infants receiving <25 ml/kg/day compared with infants receiving ≥50 ml/kg/day of human milk in the first 28 days of life and 16.2% higher compared with infants receiving 25-49.99 ml/kg/day of human milk. These costs only included the initial NICU hospitalization costs, and it is likely that the societal cost savings may be even larger due to the subsequent costs of health care and special education services to care for long-term health and neurodevelopmental problems.
In a study published in Neonatology in March 2015, we examined the cost savings of human milk in reducing the incidence of NEC in 291 infants from the same prospective cohort study of VLBW infants admitted to Rush University Medical Center between 2008 and 2012.3 We found that infants who received any formula in days 1-14 post-birth were 3.5 times as likely to acquire NEC as infants without formula (p = 0.020), and NEC was associated with an additional $43,818 in NICU hospitalization costs (in 2012 US dollars). We also found that each additional ml/kg/day of human milk in the first 14 days post-birth was associated with a cost savings of $534 in NICU-related costs. That is, increasing the average daily dose of human milk by 17.9 ml/kg/day in the first 14 days post-birth (a 1 standard deviation increase) is associated with a cost savings of $9,559.
While more work is needed to more completely understand the cost savings of human milk across other potentially avoidable morbidities in VLBW infants, results from these two studies suggest that both the avoidance of formula and the dose of human milk are important for reducing the incidence of both late onset sepsis and NEC. Additionally, the critical window for human milk feedings is at least the first 28 days post-birth to reduce the incidence of both late onset sepsis and NEC.
Did you miss part one of Tricia’s economics of human milk blog series?
Read it here: Unraveling the Cost of Very Low Birth Weight Infants
1. Bigger HR, Fogg LJ, Patel A, Johnson T, Engstrom JL, Meier PP. Quality indicators for human milk use in very low-birthweight infants: Are we measuring what we should be measuring? Journal of Perinatology 2014;1-5.
2. Patel AL, Johnson TJ, Engstrom JL, Fogg L, Jegier BJ, Bigger HR, Meier PP. Impact of early human milk on sepsis and health-care costs in very low birth weight infants. Journal of Perinatology 2013;1-6.
3. Johnson TJ, Patel AL, Bigger HR, Engstrom JL, Meier PP. Cost savings of human milk as a strategy to reduce the incidence of necrotizing enterocolitis in very low birth weight infants. Neonatology 2015;107:271-6.