Cost-Effectiveness of NICU Infant Feeding

Most Level III and Level IV neonatal intensive care units currently use donor human milk (DHM) as a supplement to infant feedings when mother’s own milk (MOM) is not available. However, it can be challenging to prove cost-effectiveness.

In addition, while DHM may be used, it is used differently in different settings.¹ Its use may be restricted to infants under 28 weeks and up to 32 weeks, and with weights ranging from less than 1,000 grams to less than 1,800 grams. Some of this may depend on institutional experience with DHM and its effect or perceived effect on the occurrence of necrotizing enterocolitis (NEC). Many studies have shown that the use of human milk and human milk products can decrease, although not eliminate, the incidence and severity of NEC.^2,3,4 Ultimately, though, the decision about who should receive DHM and for how long rests on calculations or estimations of cost-effectiveness. Several publications exist now to provide some estimation of this, although individual costs and cost savings may still vary considerably.

Many of these publications calculate the cost savings of a DHM diet based only on savings in NEC costs.  Ganapathy, Hay & Kim (2012) report on the cost savings of an exclusive human milk diet, including human-human milk fortification which continues to have slow adoption related to cost concerns.  Besides cost savings related to NEC prevention or less surgical NEC, they found an overall cost savings in length of stay with a difference of 3.9 days.⁵ Berenz, Johnson, Sulo et al (abstract, PAS 2019) presented an economic summary of DHM use in infants under 1,500 grams. They calculated feeding costs of $1,317 for infants receiving a DHM diet and $936 for formula fed infants. Importantly, this was a comparison before and after the implementation of DHM. They calculated cost savings based on cost of prevented NEC cases and found a small cost savings of $1,860 per percentage point reduction of NEC. They conclude that units with a higher rate of NEC are likely to see a greater cost savings. Indeed, units with high rates of NEC were some of the first to adopt the use of DHM, whether limited to donor milk only or to include human-human milk fortifier as this presents the greatest case for cost savings.

Carroll & Herrmann (2013) estimated the costs of DHM use based solely on use and not on the potential or theoretical cost savings of NEC cases prevented or decreased length of stay which would be less if NEC cases are less.⁶ In this study, charts were reviewed and costs included if infants fell into one of four categories. These included those fed only DHM (mother not providing any milk), those receiving MOM and being supplemented with DHM, those receiving MOM and being supplemented with infant formula, and those receiving formula only. Infants were eligible if less than 32 weeks gestation, since this was their criteria for DHM use. The estimated cost of DHM was $4 per ounce, which is fairly standard in the U.S. today as well. The total cost of DHM to the hospital over one year was $10,898, with the average cost being $236.90 per infant. This group does not mention formula costs as most hospitals who are Baby Friendly are purchasing infant formula now, although in many cases the cost is offset in some manner.  Neither are the costs of fortifier included. While many places continue to use bovine-based fortifiers, there is more and more evidence that delaying exposure to bovine proteins is beneficial. Nevertheless, they showed a cost range per baby of $27 to $590.90, with the lowest costs being in the group where MOM was used primarily and the highest cost in the group where mother was not providing any milk and only DHM was used from birth to 33 weeks corrected gestational age.

In addition, we shouldn’t forget about the cost of mothers providing their own milk. In the abstract presentation by Berenz (PAS, 2019), this cost was also included. Jegeir, Johnson, Engstrom et al (2013) calculated the cost of obtaining MOM. They included the cost of breast pump rental, one-time cost of pump kit purchase, and the cost of purchasing food grade containers for storage of pumped milk. They found that if mothers pumped at least 100 ml per day, they had lower acquisition charges than if DHM or infant formula was used for feeding.⁷

Some have advocated including costs to the mother, such as an enhanced diet and potentially time off work to pump. MOM is often viewed as “free,” but clearly providing this milk to an infant in the NICU is not easy or financially “free” and requires support from a variety of people and use of specialized equipment. Certainly, it is likely to be more successful with the appropriate pump, often provided through insurance. Healthcare economists are much better qualified to calculate these costs, and this could certainly enhance our understanding of the hidden costs of infant feeding.

At one hospital where I was involved in trying to bring in donor milk, the hospital finance folks said, “we pay for the food we feed to patients in other areas of the hospital, so we should pay for the food we feed to the infants.” This was in regards to covering the costs of milk for the infant versus billing the patient for the costs. Nevertheless, many are left with the task of justifying these costs that show merely as a line item on a budget.

Arguments to bring in the more expensive human-human milk fortifier are more difficult in units where the rate of NEC is already very low. Even in some studies mentioned in this review, rates of NEC being low show a less dramatic cost savings when using DHM, and this savings is likely to be even less with the use of human-human milk fortifier. One can estimate the number of NEC cases that would be or have been prevented to show a larger cost benefit and certainly human benefit. However, there are other, more tangible benefits that may be possible.

One study mentioned already showed a decrease in length of stay of up to 3.9 days. Of course, when NEC is prevented, length of stay will decrease. Trang, Zupancic, Unger et al (2018) looked at cost savings up to 18 months of age. They included healthcare encounters after discharge and days off work to care for infants who may not have been sick enough for a healthcare encounter, but were too sick for parents to go to work. They found no significant difference in costs between use of donor milk and formula as a supplement for mother’s own milk during the hospital stay, but did find a significant difference after discharge when these items were included.⁸ This study had some limitations, such as parents’ own report of costs based on their recollection, but merits further study in the long-term benefit.

In summary, supporting mothers in their effort to start, increase, and maintain milk supply is the basic level of infant nutrition that should be provided.  There are now several studies analyzing the cost of DHM use, based on a variety of criteria for use. Some studies also include the use of human-human milk fortifiers and bovine-based fortifiers, as delaying exposure to bovine proteins has been shown to have some effect on incidence and/or severity of NEC.

Resources:

1. Hagadorn, J. I., Brownell, E. A., Lussier, M. M., Parker, M. G., & Herson, V. C. (2016). Variability of criteria for pasteurized donor human milk use: a survey of US neonatal intensive care unit medical directors. Journal of Parenteral and Enteral Nutrition, 40(3), 326-333.
2. Schanler RJ, Shulman RJ, Lau C. Feeding strategies for premature infants: Beneficial outcomes of feeding fortified human milk vs. preterm formula. Pediatrics 1999;103:1150–1157.
3. Meinzen-Derr J, Poindexter B, Wrage L, et al. Role of human milk in extremely low birth weight infants’ risk of necrotizing enterocolitis or death. J Perinatol 2009;29:57–62.
4. Furman L, Taylor G, Minich N, et al. The effect of maternal milk on neonatal morbidity of very low-birth weight infants. Arch Pediatr Adolesc Med 2003;157:66–71.
5. Ganapathy, V., Hay, J. W., & Kim, J. H. (2012). Costs of necrotizing enterocolitis and cost-effectiveness of exclusively human milk-based products in feeding extremely premature infants. Breastfeeding medicine, 7(1), 29-37.
6. Carroll, K., & Herrmann, K. R. (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), 286-290.
7. Jegier, B. J., Johnson, T. J., Engstrom, J. L., Patel, A. L., Loera, F., & Meier, P. (2013). The institutional cost of acquiring 100 mL of human milk for very low birth weight infants in the neonatal intensive care unit. Journal of Human Lactation, 29(3), 390-399.
8. Trang, S., Zupancic, J. A., Unger, S., Kiss, A., Bando, N., Wong, S., … & O’Connor, D. L. (2018). Cost-effectiveness of supplemental donor milk versus formula for very low birth weight infants. Pediatrics, 141(3), e20170737.