US state policies for Medicaid coverage of donor human milk

National Trends in Breastfeeding by Gestational Age Category

National breastfeeding (direct breastfeeding and/or provision of pumped breast milk) rates among preterm infants are unclear. We report rates of breastfeeding initiation and continuation at 12 weeks after birth by gestational age category from a nationally representative survey between 2009 and 2019. Breastfeeding rates were lowest among infants born late preterm compared with other gestational age categories.

Factors Associated with Inequities in Donor Milk Bank Access Among Different Hospitals

Objective: Donor human milk (DHM) can provide many benefits to neonates. This study examines access to DHM and how structural barriers may exacerbate inequities. Study Design: The median test and analysis of variance test were used to compare the distribution of maternal race/ethnicity and insurance status variables with DHM access for California neonatal intensive care units (NICUs) in 2021. Results: Across 124 NICUs, those serving a higher percentage of white families were more likely to have access to DHM (p = 0.04). NICUs with a higher percentage of Hispanic families were less likely to have access to DHM (p = 0.03). Hospitals that had higher proportions of uninsured patients were also less likely to have access to DHM (p = 0.015). Conclusion: Inequities in DHM access and use among NICU infants begin at the structural level. Policies that reduce barriers to DHM access may reduce health inequities for Hispanic and uninsured families.

Maternity care practices supportive of breastfeeding in U.S. advanced neonatal care units, United States, 2022

OBJECTIVE

To describe breastfeeding-supportive practices in U.S. maternity hospitals with advanced neonatal care units (ANCU).

STUDY DESIGN

Using 2022 mPINC data, we calculated the percent of hospitals reporting (1) breastfeeding-supportive practices for "most" (≥80%) mother-baby dyads in ANCUs, by hospital demographic characteristics and (2) infant receipt of mother's own milk or donor milk at any time while in the ANCU, by ANCU level.

RESULTS

More than 90% of hospitals reported that "most" mothers (≥80%) were advised on some breastfeeding-supportive practices. Fewer hospitals reported that "most" mothers expressed milk within one hour of birth (37%) or that kangaroo care was practiced for "most" eligible newborns (63%). Receipt of mother's own milk varied by unit level and state.

CONCLUSION

Breastfeeding-supportive practices requiring the technical competency of healthcare providers (e.g., early milk expression, kangaroo care) are less likely to be implemented in ANCU settings compared to practices centered around providing advice or education.

When a baby is born, so is a parent: Understanding the effects of preterm birth on Black parents through the lens of the NIMHD framework

BACKGROUND

The rate of preterm birth (PTB) is high in the United States and Black infants remain disproportionately affected, with the disparity between Black and White infant deaths greater today than it was under antebellum slavery.

PURPOSE

The National Institute on Minority Health and Disparities Research Framework reflects a unique set of determinants relevant to the understanding and promotion of minority health.

METHODS

We have applied this framework to better understand the effects of PTB on Black parents and the distribution of the social determinants of health, including structural determinants and root causes of inequities.

DISCUSSION

This adaptation shows the intersection in maternal and infant health that shapes individuals' experiences, drives disparities and impacts perinatal outcomes in critical periods over the lifecourse.

CONCLUSION

In our efforts to achieve health equity, it is imperative that we study the underlying mechanisms and recognize that policies, institutional structures, and social factors are drivers of racism.

The entwined circles of quality improvement & advocacy

Health policy and quality improvement initiatives exist symbiotically. Quality projects can be spurred by policy decisions, such as the creation of financial incentives for high-value care. Then, advocacy can streamline high-value care, offering opportunities for quality improvement scholars to create projects consistent with evidenced-based care. Thirdly, as pediatrics and neonatology reconcile with value-based payment structures, successful quality initiatives may serve as demonstration projects, illustrating to policy-makers how best to allocate and incentivize resources that optimize newborn health. And finally, quality improvement (QI) can provide an essential link between broad reaching advocacy principles and boots-on-the-ground local or regional efforts to implement good ideas in ways that work practically in particular environments. In this paper, we provide examples of how national legislation elevated the importance of QI, by penalizing hospitals for low quality care. Using Medicaid coverage of pasteurized human donor milk as an example, we discuss how advocacy improved cost-effectiveness of treatments used as tools for quality projects related to reduction of necrotizing enterocolitis and improved growth. We discuss how the future of QI work will assist in informing the agenda as neonatology transitions to value-based care. Finally, we consider how important local and regional QI work is in bringing good ideas to the bedside and the community.

A systematic review of contaminants in donor human milk

Donor human milk (DHM) from a milk bank is the recommended feeding method for preterm infants when the mother's own milk (MOM) is not available. Despite this recommendation, information on the possible contamination of donor human milk and its impact on infant health outcomes is poorly characterised. The aim of this systematic review is to assess contaminants present in DHM samples that preterm and critically ill infants consume. The data sources used include PubMed, EMBASE, CINAHL and Web of Science. A search of the data sources targeting DHM and its potential contaminants yielded 426 publications. Two reviewers (S. T. and D. L.) conducted title/abstract screening through Covidence software, and predetermined inclusion/exclusion criteria yielded 26 manuscripts. Contaminant types (bacterial, chemical, fungal, viral) and study details (e.g., type of bacteria identified, study setting) were extracted from each included study during full-text review. Primary contaminants in donor human milk included bacterial species and environmental pollutants. We found that bacterial contaminants were identified in 100% of the papers in which bacterial contamination was sought (16 papers) and 61.5% of the full data set (26 papers), with the most frequently identified genera being Staphylococcus (e.g., Staphylococcus aureus and coagulase-negative Staphylococcus) and Bacillus (e.g., Bacillus cereus). Chemical pollutants were discovered in 100% of the papers in which chemical contamination was sought (eight papers) and 30.8% of the full data set (26 papers). The most frequently identified chemical pollutants included perfluoroalkyl substances (six papers), toxic metal (one paper) and caffeine (one paper). Viral and fungal contamination were identified in one paper each. Our results highlight the importance of establishing standardisation in assessing DHM contamination and future studies are needed to clarify the impact of DHM contaminants on health outcomes.

Advocacy in neonatology: current issues and introduction to the series

Advocacy is an increasingly important skill for neonatologists. As social factors play a greater influence on short & long-term newborn outcomes, neonatal physicians must be attentive to policy factors and work to ensure they benefit the health of both patients and the specialty. In this article, we review advocacy issues of current relevance to neonatal practice, including the "Born Alive Executive Order," the "Newborn Screening Saves Lives Act," subspecialty loan repayment and legislation related to donor human milk, as well as introduce topics further discussed as part of the American Academy of Pediatrics Section on Neonatal-Perinatal Medicine Advocacy Series.

Medicaid and newborn care: challenges and opportunities

Since its creation in 1965, Medicaid has operated as a federal-state partnership that provides a robust set of medical benefits to low-income families, including pregnant people and infants. In many ways, Medicaid has met its initial promise. However, medical benefits, provider payments, and key administrative procedures regarding eligibility, enrollment, and access to care vary substantially among state Medicaid programs. These variations have created profound inequities across states in the care of parents and children, particularly during pregnancy and in the postpartum and neonatal periods. Here we review select aspects of the Medicaid program pertinent to newborns and infants that contribute to eligibility and enrollment gaps, variations in benefits coverage and payment rates, and racial disparities in both access to healthcare and infant health outcomes. We outline a number of structural reforms of the Medicaid program that can improve newborn and infant access to care and outcomes and redress existing inequities.

Supporting Families Facing Lactation Anaphylaxis: A Case Report

Lactation anaphylaxis is a rare condition that may occur consequent to breastfeeding. Early identification and management of symptoms is paramount to the physical well-being of the birthing person. Supporting newborn feeding goals is also a key component of care. In cases in which the birthing person wants to exclusively feed human milk, planning should include streamlined access to donor milk. Clear communication between health care providers and developing systems to access donor milk for parental indications may help address barriers.

Perceptions of Human Milk Banks as a Response to the US Infant Formula Shortage: A Mixed Methods Study of US Mothers

Human donor milk from established milk banks is the safest alternative to mother’s own milk. The current study examined US mothers’ perceptions of human milk banks as a response to the ongoing infant formula shortage in the United States. A cross-sectional study with closed and open-ended items was administered through nine Facebook groups, and a final sample of 863 responses was retained in the study. We used descriptive and inferential statistics for statistical analysis, and content and thematic analyses were conducted on open-ended responses. In our sample, 77.4% of respondents perceived human milk banking as a feasible response to the formula shortage crisis. Marital status, education, religion, and willingness to donate milk were associated with respondent perceptions of milk banking as a response to the formula shortage. US mothers’ concerns around the accessibility of milk banks and the cost of human milk were the primary reasons accounting for the hesitancy toward milk banking as a response to the infant formula shortage crisis. The study findings indicate support for milk banking as a potential ‘temporary’ solution to the formula shortage and reveal that milk banking is a tool that is currently being underutilized. It is imperative that stakeholders address the challenges identified by the current study to improve infant feeding and health.