Influence of own mother's milk on bronchopulmonary dysplasia and costs

BACKGROUND

Human milk from the infant's mother (own mother's milk; OMM) feedings reduces the risk of several morbidities in very low birthweight (VLBW) infants, but limited data exist regarding its impact on bronchopulmonary dysplasia (BPD).

OBJECTIVE

To prospectively study the impact of OMM received in the neonatal intensive care unit (NICU) on the risk of BPD and associated costs.

DESIGN/METHODS

A 5-year prospective cohort study of the impact of OMM dose on growth, morbidity and NICU costs in VLBW infants. OMM dose was the proportion of enteral intake that consisted of OMM from birth to 36 weeks postmenstrual age (PMA) or discharge, whichever occurred first. BPD was defined as the receipt of oxygen and/or positive pressure ventilation at 36 weeks PMA. NICU costs included hospital and physician costs.

RESULTS

The cohort consisted of 254 VLBW infants with mean birth weight 1027±257 g and gestational age 27.8±2.5 weeks. Multivariable logistic regression demonstrated a 9.5% reduction in the odds of BPD for every 10% increase in OMM dose (OR 0.905 (0.824 to 0.995)). After controlling for demographic and clinical factors, BPD was associated with an increase of US$41 929 in NICU costs.

CONCLUSIONS

Increased dose of OMM feedings from birth to 36 weeks PMA was associated with a reduction in the odds of BPD in VLBW infants. Thus, high-dose OMM feeding may be an inexpensive, effective strategy to help reduce the risk of this costly multifactorial morbidity.

Barriers to Human Milk Feeding at Discharge of Very Low-Birthweight Infants: Evaluation of Neighborhood Structural Factors

BACKGROUND

Although 98% of mothers in our cohort initiated human milk (HM) provision for their very low-birthweight (VLBW) infants, fewer black infants received HM at neonatal intensive care unit (NICU) discharge than non-black infants. This study examined neighborhood structural factors associated with HM feeding at discharge to identify potential barriers.

MATERIALS AND METHODS

Sociodemographic and HM data were prospectively collected for 410 VLBW infants and mothers. Geocoded addresses were linked to neighborhood structural factors. Bivariate and multivariate logistic regression analyses were conducted for the entire cohort and racial/ethnic subgroups.

RESULTS

HM feeding at discharge was positively correlated with further distance from Women, Infants, and Children (WIC) office, less violent crime, less poverty, greater maternal education, older maternal age, greater infant gestational age, and shorter NICU hospitalization. Multivariate analysis demonstrated that only maternal race/ethnicity, WIC eligibility, and length of NICU hospitalization predicted HM feeding at discharge for the entire cohort. The interaction between access to a car and race/ethnicity significantly differed between black and white/Asian mothers, although the predicted probability of HM feeding at discharge was not significantly affected by access to a car for any racial/ethnic subgroup.

CONCLUSIONS

Neighborhood structural factors did not significantly impact HM feeding at discharge. However, lack of access to a car may be a factor for black mothers, potentially representing restricted HM delivery to the NICU or limited social support, and warrants further study.

Cost savings of human milk as a strategy to reduce the incidence of necrotizing enterocolitis in very low birth weight infants

BACKGROUND

Necrotizing enterocolitis (NEC) is a costly morbidity in very low birth weight (VLBW; <1,500 g birth weight) infants that increases hospital length of stay and requires expensive treatments.

OBJECTIVES

To evaluate the cost of NEC as a function of dose and exposure period of human milk (HM) feedings received by VLBW infants during the neonatal intensive care unit (NICU) hospitalization and determine the drivers of differences in NICU hospitalization costs for infants with and without NEC.

METHODS

This study included 291 VLBW infants enrolled in an NIH-funded prospective observational cohort study between February 2008 and July 2012. We examined the incidence of NEC, NICU hospitalization cost, and cost of individual resources used during the NICU hospitalization.

RESULTS

Twenty-nine (10.0%) infants developed NEC. The average total NICU hospitalization cost (in 2012 USD) was USD 180,163 for infants with NEC and USD 134,494 for infants without NEC (p = 0.024). NEC was associated with a marginal increase in costs of USD 43,818, after controlling for demographic characteristics, risk of NEC, and average daily dose of HM during days 1-14 (p < 0.001). Each additional ml/kg/day of HM during days 1-14 decreased non-NEC-related NICU costs by USD 534 (p < 0.001).

CONCLUSIONS

Avoidance of formula and use of exclusive HM feedings during the first 14 days of life is an effective strategy to reduce the risk of NEC and resulting NICU costs in VLBW infants. Hospitals investing in initiatives to feed exclusive HM during the first 14 days of life could substantially reduce NEC-related NICU hospitalization costs.

Assessing preventability of maternal mortality in Illinois: 2002-2012

OBJECTIVE

We sought to describe the potential preventability of pregnancy-related deaths in Illinois from 2002 through 2012 as determined by perinatal centers following the Illinois maternal death review process.

STUDY DESIGN

We conducted a retrospective review of all known maternal deaths in the state from 2002 through 2012 with complete records in the Illinois Department of Public Health's Maternal Mortality Review Form database. The association between causes of death and potential preventability was analyzed for pregnancy-related deaths.

RESULTS

There were 610 maternal deaths in Illinois during the study period (31.8 per 100,000 live births). One-third of maternal deaths (n = 210) were directly or indirectly related to pregnancy, 7.0% (n = 43) were possibly related, and 52.6% (n = 321) were unrelated. Vascular causes were the most common cause of pregnancy-related death, followed by cardiac causes and hemorrhage. One-third of deaths directly or indirectly related to pregnancy were deemed potentially preventable. Hemorrhage and deaths due to psychiatric causes were most likely to be considered avoidable, while cancer and vascular-related deaths were generally not considered preventable.

CONCLUSION

This analysis of pregnancy-related deaths in Illinois, the first in >60 years, found similar causes of death and potential preventability as pregnancy-related death reviews in other states. Analyzing the causes of pregnancy-related death is a critical and necessary step in improving maternal health outcomes, particularly in decreasing potentially preventable pregnancy-related deaths. Greater attention should be directed toward intervening on the provider, systems, and patient factors contributing to preventable deaths.

Economic benefits and costs of human milk feedings: a strategy to reduce the risk of prematurity-related morbidities in very-low-birth-weight infants

Infants born at very low birth weight (VLBW; birth weight <1500 g) are at high risk of mortality and are some of the most expensive patients in the hospital. Additionally, VLBW infants are susceptible to prematurity-related morbidities, including late-onset sepsis, bronchopulmonary dysplasia (BPD), necrotizing enterocolitis, and retinopathy of prematurity, which have short- and long-term economic consequences. The incremental cost of these morbidities during the neonatal intensive care unit (NICU) hospitalization is high, ranging from $10,055 (in 2009 US$) for late-onset sepsis to $31,565 for BPD. Human milk has been shown to reduce both the incidence and severity of some of these morbidities and, therefore, has an indirect impact on the cost of the NICU hospitalization. Furthermore, human milk may also directly reduce NICU hospitalization costs, independent of the indirect impact on the incidence and/or severity of these morbidities. Although there is an economic cost to both the mother and institution for providing human milk during the NICU hospitalization, these costs are relatively low. This review describes the total cost of the initial NICU hospitalization, the incremental cost associated with these prematurity-related morbidities, and the incremental benefits and costs of human milk feedings during critical periods of the NICU hospitalization as a strategy to reduce the incidence and severity of these morbidities.

Impact of early human milk on sepsis and health-care costs in very low birth weight infants

OBJECTIVE

To study the incidence of sepsis and neonatal intensive care unit (NICU) costs as a function of the human milk (HM) dose received during the first 28 days post birth for very low birth weight (VLBW) infants.

STUDY DESIGN

Prospective cohort study of 175 VLBW infants. The average daily dose of HM (ADDHM) was calculated from daily nutritional data for the first 28 days post birth (ADDHM-Days 1-28). Other covariates associated with sepsis were used to create a propensity score, combining multiple risk factors into a single metric.

RESULT

The mean gestational age and birth weight were 28.1 ± 2.4 weeks and 1087 ± 252 g, respectively. The mean ADDHM-Days 1-28 was 54 ± 39 ml kg(-1) day(-1) (range 0-135). Binary logistic regression analysis controlling for propensity score revealed that increasing ADDHM-Days 1-28 was associated with lower odds of sepsis (odds ratio 0.981, 95% confidence interval 0.967-0.995, P=0.008). Increasing ADDHM-Days 1-28 was associated with significantly lower NICU costs.

CONCLUSION

A dose-response relationship was demonstrated between ADDHM-Days 1-28 and a reduction in the odds of sepsis and associated NICU costs after controlling for propensity score. For every HM dose increase of 10 ml kg(-1) day(-1), the odds of sepsis decreased by 19%. NICU costs were lowest in the VLBW infants who received the highest ADDHM-Days 1-28.

Supporting breastfeeding in the neonatal intensive care unit: Rush Mother's Milk Club as a case study of evidence-based care

The translation of the evidence for the use of human milk (HM) in the neonatal intensive care unit (NICU) into best practices, toolkits, policies and procedures, talking points, and parent information packets is limited, and requires use of evidence-based quality indicators to benchmark the use of HM, consistent messaging by the entire NICU team about the importance of HM for infants in the NICU, establishing procedures that protect maternal milk supply, and incorporating lactation technologies that take the guesswork out of HM feedings and facilitate milk transfer during breastfeeding.

Mothers' performing creamatocrit measures in the NICU: accuracy, reactions, and cost

OBJECTIVE

To determine whether mothers of infants in the neonatal intensive-care unit could be taught to perform creamatocrits (CRCTs) accurately on own mothers' milk (OMM). These mothers' reactions to performing CRCTs also were measured.

SAMPLE

Twenty-six mothers and four advanced-practice nurses (RNs) participated in this study.

DESIGN

For Phase One of this blinded trial, mothers were taught to perform the CRCT by one of the two instructional RNs. For Phase Two, mothers and one of the two validation RNs performed CRCTs simultaneously and independently on the same OMM sample, and the mother completed a Maternal Reactions questionnaire.

RESULTS

Mothers' CRCT measures were highly accurate. The mean absolute difference between RNs' and mothers' CRCTs was 0.69%, with 50% and 84.6% of these differences, respectively, < or = 0.5% and < or = 1.0% CRCT. A strong linear correlation was noted between RNs' and mothers' CRCTs. Ninety-six percent of the mothers reported that the CRCT was easy to learn, they felt comfortable performing the procedure, and it made them feel more involved in infant care. A mean of 23.6 minutes was spent teaching the mother to perform CRCT, a figure that reflects the cost-effectiveness of the approach.

CONCLUSION

Mothers can be taught to perform CRCTs accurately and easily on their OMM. This practice exemplifies high quality, cost-effective care that maximizes maternal involvement and satisfaction.

Influence of increased survival in very low birth weight, low birth weight, and normal birth weight infants on the incidence of sudden infant death syndrome in the United States: 1985-1991

OBJECTIVE

To examine the relationship between infant survival and the rates sudden infant death syndrome (SIDS) in very low birth weight (VLBW), low birth weight (LBW), and normal birth weight (NBW) infants from 1985 to 1991.

METHODS

The National Center for Health Statistics Birth Cohort Linked Birth/Infant Death Data Sets were used to determine birth weight, age at death, and cause of death for US-born singleton infants with birth weights of 500 g or more.

RESULTS

Increasing infant and postneonatal survival rates were greatest in VLBW infants. In contrast, SIDS rates did not change in VLBW infants (3.66 to 3.69; P = .70) but declined in both LBW (3.51 to 3.32; P = .041) and NBW (1.07 to 1.03; P = .008) infants. Postneonatal SIDS rates (per 1000 neonatal survivors) did not change in VLBW (4.93 to 4.58; P = .58) or LBW (3.36 to 3.22; P = .07) infants but declined in NBW infants (1.00 to 0.97; P = .018). Although there were differences among the slopes of survival rates, there was no statistical evidence of differences in the slope of SIDS rates among the three groups.

CONCLUSIONS

The marked increase in survival of VLBW infants increased the pool of babies at potential risk for SIDS. VLBW infants' SIDS rates have not changed while they have declined in NBW and LBW infants.

The cost of prematurity: a case-control study of twins vs singletons

OBJECTIVES

This study evaluated the extent to which morbidity and costs at birth were associated with plurality, gestational age, and birth-weight with a sample of twins from a large urban hospital.

METHODS

Each twin infant was matched to two singleton infants (control [ctrl]-singletons) for payor status and race, and to one singleton infant (gestation [ga]-singleton) for payor status, race, and gestational age; after exclusion of infants who were transferred, the study population included 111 twins, 242 ctrl-singletons, and 106 ga-singletons. Data were stratified by five gestational categories and compared across study groups. Outcomes included birthweight, neonatal diagnoses, infant length of stay, infant costs per day, and total infant and total birth costs.

RESULTS

Total birth costs ranged from $280,146 at 25 to 27 weeks to $9,803 at 39 to 42 weeks, decreasing with advancing gestation to means of $88,891 (twins), $43,041 (ga-singletons), and $9,326 (ctrl-singletons). Twins did not differ from either group of singletons in prematurity-related diagnoses, length of stay, or costs until after 34 weeks' gestation.

CONCLUSIONS

In this sample, prematurity, not plurality, was the predominant cost factor at birth. Compared with singletons, twins experienced increased morbidity and associated costs after 38 weeks' gestation.