Economic Impact of Human Milk on Medical Charges of Extremely Low Birth Weight Infants

Abstract

Dear Editor:

Premature birth is associated with substantial short- and long-term costs. In 2001, 8% of infant hospitalizations in the United States were associated prematurity or low birth weight, totaling $5.8 billion.¹ In 2005, an Institute of Medicine report estimated that the societal cost of premature birth (<37 weeks of gestation) in the United States was $26.2 billion.²

The American Academy of Pediatrics recommends human milk (HM) as the preferred nutritional choice for extremely low birth weight (ELBW) infants given the many clinical benefits.³ Although the current medical literature supports the concept that the type of nutrition affects outcomes of premature infants, the effect of nutritional type on cost of providing medical care to this patient population is unknown.

We conducted a retrospective, cohort study to evaluate the economic impact of providing HM and formula (FM) on median medical care charges (MCC) of ELBW infants. Existing data records on all surviving ELBW infants admitted to the Duke Intensive Care Nursery between January 1, 2007 and October 1, 2010 were identified. Both inpatient and outpatient charts were reviewed during the infant's initial hospitalization and subsequent medical care for up to 4 months after discharge. Cohort data for hospital and outpatient facility charges were obtained from the Duke Health Financial Database.

The HM group received maternal milk (MM), donor milk (DM), or a combination and MM and DM. Infants fed a combination of HM and FM were grouped together and represented in the “combination group.” Any FM feed in combination with HM was categorized in the combination group. During the study period HM was fortified with bovine milk-derived human milk fortifier.

Statistical analyses of the data were completed using JMP version 9.0 software (SAS Institute, Cary, NC). MCC (primary outcome) data were not normally distributed, requiring use of the Wilcoxon rank sum test to examine for differences across the various feeding groups. Pairwise comparisons were conducted using the Tukey–Kramer test. Statistical significance was defined as p<0.05. The Duke University Medical Center Institutional Review Board approved this study.

Ninety-seven surviving ELBW infants were included in the study. Twenty-four (25%) infants were fed exclusively MM, three (3%) infants exclusively DM, 18 (19%) infants MM and DM, and 13 (13%) infants FM; the remaining 39 (40%) infants were fed combinations of HM and FM (21 MM, DM, and FM; nine MM and FM; and nine DM and FM). Population demographics, length of stay, and MCC (total, inpatient, and outpatient) are presented in Table 1. All MCC for the HM group were significantly less than the combination and FM groups. All 13 infants (100%) fed exclusively FM during their birth hospitalization were re-admitted following neonatal intensive care unit (NICU) discharge. Ten of 39 (26%) infants fed HM and 11 of 45 (24%) infants fed a combination of HM and FM were re-admitted following NICU discharge. The FM group stayed in the NICU significantly longer than the HM group (64 days vs. 143 days).

Table 1.

Study Population Demographics and Medical Care Charges

	Nutritional history
	FM (n=13)	Combination (n=39)^a	HM (n=45)	p value for
GA	26 (23–30)	25 (22–29)	26 (23–30)	FM vs. combination	0.56
				FM vs. HM	0.64
				Combination vs. HM	0.02
BW (g)	710 (507–970)	740 (460–980)	830 (570–990)	FM vs. combination	0.98
				FM vs. HM	0.04
				Combination vs. HM	<0.01
5-minute	6 (4–8)	7 (1–9)	7 (2–9)	FM vs. combination	0.99
Apgar score				FM vs. HM	0.56
				Combination vs. HM	0.45
LOS (days)	143 (89–299)	120 (13–354)	64 (16–305)	FM vs. combination	0.21
				FM vs. HM	<0.01
				Combination vs. HM	<0.01
Total MCC	$768,880	$564,640	$329,647	FM vs. combination	0.31
	($366,884–$1,638,551)	($130,976–$1,944,155)	($89,760–$1,757,094)	FM vs. HM	<0.01
				Combination vs. HM	<0.01
Inpatient MCC	$731,495	$559,765	$325,943	FM vs. combination	0.38
	($346,561–$1,633,938)	($99,040–$1,937,505)	($89,760–$1,729,990)	FM vs. HM	<0.01
				Combination vs. HM	<0.01
Outpatient MCC	$21,965	$9,161	$5,333	FM vs. combination	0.29
	($3,466–$38,403)	($2,110–$32,601)	($1,620–$27,104)	FM vs. HM	<0.01
				Combination vs. HM	<0.01

Data are median (range) values.

Both human milk (HM) and formula (FM).

BW, birth weight; GA, gestational age; LOS, length of stay; MCC, median medical care charges.

Given the remarkable societal cost of providing care to premature infants, implementing strategies aimed at reducing these costs and improving outcomes is essential. This single-site study suggests that the charges associated with caring ELBW infants are significantly affected by the type of nutrition provided during their birth hospitalization. Infants receiving any type of HM had lower MCC, shorter length of stay, and fewer re-hospitalizations compared with infants provided FM. Infants fed exclusively FM had similar MCC and length of stay to those fed a combination of HM and FM, suggesting that any amount of HM is beneficial to the ELBW infant.

Our report provides an estimate of the savings that would be balanced against the costs of implementing these programs. This information would be useful in planning studies of cost-effectiveness of implementation of policies and procedures to optimize mothers' provision of milk for their ELBW infants. The United Kingdom's Health Technology Assessment program recently reviewed the effectiveness and cost-effectiveness of interventions that promote or inhibit breastfeeding or HM feedings for neonates.⁴ The authors found that kangaroo skin-to-skin contact, in-hospital and postdischarge peer support, simultaneous breastmilk pumping, multidisciplinary staff training, the Baby Friendly accreditation of the associated maternity hospital, and skilled support from trained staff in the hospital are potentially cost-effective.⁴

The strengths of this study include the comprehensive dataset analyzed for each baby and the fact that the infants were from a single center, limiting the treatment center variability known to occur and affect outcomes. Weaknesses include the fact that we analyzed total hospital charges, which are known to significantly differ from actual hospital costs and what is actually reimbursed by payers. Finally, the differences in the population characteristics are a weakness. The combination group was born at a younger gestational age and weighed less at birth compared with the HM group, and the FM group weighed less at birth than the HM group.

Feeding with HM provides medical, psychosocial, and economic benefits in term and preterm infants, and the American Academy of Pediatrics, World Health Organization, and UNICEF recommend practices for hospitals to optimize opportunities for mothers to provide milk for their infants. Economic analysis of the use of HM and FM in our center provides a financial rationale for institutional adoption of initiatives that result in maximizing mothers' opportunities to provide HM as the routine source of nutrition for ELBW infants.

References

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Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics, 2012; 129:e827–e841.

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