ObjectiveTo 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 DesignProspective cohort study of 175 VLBW infants. Average daily dose of HM (ADDHM) was calculated from daily nutritional data for the first 28 days post-birth (ADDHM-Days1-28). Other covariates associated with sepsis were used to create a propensity score, combining multiple risk factors into a single metric.ResultThe mean gestational age and birth weight were 28.1 ± 2.4 wk and 1087 ± 252 g, respectively. The mean ADDHM-Days1-28 was 54 ± 39 mL/kg/d (range 0-135). Binary logistic regression analysis controlling for propensity score revealed that increasing ADDHM-Days1-28 was associated with lower odds of sepsis (OR .981, 95%CI .967-.995, p=.008). Increasing ADDHM-Days1-28 was associated with significantly lower NICU costs.ConclusionA dose-response relationship was demonstrated between ADDHM-Days1-28 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/d, the odds of sepsis decreased by 19%. NICU costs were lowest in the VLBW infants who received the highest ADDHM-Days1-28.

The aim of this study was to quantify the excess cases of pediatric and maternal disease, death, and costs attributable to suboptimal breastfeeding rates in the United States. Using the current literature on the associations between breastfeeding and health outcomes for nine pediatric and five maternal diseases, we created Monte Carlo simulations modeling a hypothetical cohort of U.S. women followed from age 15 to age 70 years and their children from birth to age 20 years. We examined disease outcomes using (a) 2012 breastfeeding rates and (b) assuming that 90% of infants were breastfed according to medical recommendations. We measured annual excess cases, deaths, and associated costs, in 2014 dollars, using a 2% discount rate. Annual excess deaths attributable to suboptimal breastfeeding total 3,340 (95% confidence interval [1,886 to 4,785]), 78% of which are maternal due to myocardial infarction (n = 986), breast cancer (n = 838), and diabetes (n = 473). Excess pediatric deaths total 721, mostly due to Sudden Infant Death Syndrome (n = 492) and necrotizing enterocolitis (n = 190). Medical costs total $3.0 billion, 79% of which are maternal. Costs of premature death total $14.2 billion. The number of women needed to breastfeed as medically recommended to prevent an infant gastrointestinal infection is 0.8; acute otitis media, 3; hospitalization for lower respiratory tract infection, 95; maternal hypertension, 55; diabetes, 162; and myocardial infarction, 235. For every 597 women who optimally breastfeed, one maternal or child death is prevented. Policies to increase optimal breastfeeding could result in substantial public health gains. Breastfeeding has a larger impact on women's health than previously appreciated.

The feeding of human milk (milk from the infant's own mother; excluding donor milk) during the NICU stay reduces the risk of short-and long-term morbidities in premature infants, including: enteral feed intolerance; nosocomial infection; necrotizing enterocolitis (NEC); chronic lung disease (CLD); retinopathy of prematurity (ROP); developmental and neurocognitive delay; and rehospitalization after NICU discharge.1 -29 The mechanisms by which human milk provides this protection are varied and synergistic, and appear to change over the course of the NICU stay.30 , 31 In brief, these mechanisms include specific human milk components that are not present in the milk of other mammals, such the type and amount of long-chain polyunsaturated fatty acids and digestible proteins, and the extraordinary number of oligosaccharides (approximately 130). 32 Human milk also contains multiple lines of undifferentiated stem cells, with the potential to impact a variety of health outcomes through the lifespan.33 Other human milk mechanisms change over the course of lactation in a manner that complements the infant's nutritional and protective needs. These mechanisms include immunological, anti-infective, anti-inflammatory, epigenetic, and mucosal membrane protecting properties.34 -41 Thus, human milk from the infant's mother cannot be replaced by commercial infant or donor human milk, and the feeding of human milk should be a NICU priority.Recent evidence suggests that the impact of human milk on improving infant health outcomes and reducing the risk of prematurity-specific morbidities appears to be linked to specific critical exposure periods in the post-birth period during which the exclusive use of human milk and the avoidance of commercial formula may be most important. 29-31, 42, 43 Similarly, there are other periods when high doses, but not necessarily exclusive use of human milk, may be important. This chapter will review the concept of "dose and exposure period" for human milk feeding in the NICU to precisely measure and benchmark the amount and timing of human milk use in the NICU. Similarly, the critical exposure periods when exclusive or high doses of human milk appear to have the greatest impact on specific

Objective The objective of this study was to determine the association between direct costs for the initial neonatal intensive care unit (NICU) hospitalization and four potentially preventable morbidities in a retrospective cohort of very low birth weight infants (VLBW; <1500g birth weight). Methods The sample included 425 VLBW infants born alive between July 2005 and June 2009 at Rush University Medical Center. Morbidities included brain injury, necrotizing enterocolitis, bronchopulmonary dysplasia, and late onset sepsis. Clinical and economic data were retrieved from the institution’s system-wide data warehouse and cost accounting system. A general linear regression model was fit to determine incremental direct costs associated with each morbidity. Results After controlling for birth weight, gestational age, and socio-demographic characteristics, the presence of brain injury was associated with a $12,048 (p=0.005) increase in direct costs; necrotizing enterocolitis with a $15,440 (p=0.005) increase; bronchopulmonary dysplasia with a $31,565 (p<0.001) increase; and late onset sepsis with a $10,055 (p<0.001) increase in direct costs. The absolute number of morbidities was also associated with significantly higher costs. Conclusions This study provides the first collective estimates of the direct costs during the NICU hospitalization for these four morbidities in VLBW infants. The incremental costs associated with these morbidities were high, and these data can inform future studies evaluating interventions to prevent or reduce these costly morbidities.

ObjectiveCurrently, there is no standardized approach to the calculation of growth velocity (GV; g/kg/day) in hospitalized very low birth weight (VLBW) infants. Thus, differing methods are used to estimate GV, resulting in different medical centers and studies reporting growth results that are difficult to compare. The objective of this study was to compare actual GV calculated from infant daily weights during hospitalization in a Neonatal Intensive Care Unit (NICU) with estimated GV using two mathematical models that have previously been shown to provide good estimated GVs in extremely low birth weight infants: an exponential model (EM) and a 2-Point model (2-PM).Study DesignDaily weights from 81 infants with birth weights of 1000–1499g were used to calculate actual GV in daily increments from two starting points: (1) birth and (2) day of life of regaining birth weight. These daily GV values were then averaged over the NICU stay to yield overall NICU GV from the two starting points. We compared these actual GV with estimated GV calculated using the EM and 2-PM methods.ResultsThe mean absolute difference between actual and EM estimates of GV demonstrated <1% error for 100% of infants from both starting points. The mean absolute difference between actual and 2-PM estimates demonstrated <1% error for only 38% and 44% of infants from birth and regaining birth weight, respectively. The EM was unaffected by decreasing BW and increasing length of NICU stay, while the accuracy of the 2-PM was diminished significantly (p<.001) by both factors.ConclusionsIn contrast to the 2-PM, the EM provides an extremely accurate estimate of growth velocity in larger VLBW infants, and its accuracy is unaffected by common infant factors. The EM has now been validated for use in all VLBW infants to assess growth and provides a simple-to-use and consistent approach.

Objective This study compared the effectiveness, efficiency, comfort and convenience of newly designed breast pump suction patterns (BPSPs) that mimic sucking of the breastfeeding human infant during the initiation and maintenance of lactation. Methods 105 mothers of premature infants ≤ 34 weeks of gestation were randomly assigned to 1 of 3 groups within 24 hours post-birth. Each group tested 2 BPSPs; an initiation BPSP was used until the onset of lactogenesis II (OOL-II) and a maintenance BPSP was used thereafter. Results Mothers who used the experimental initiation and the standard 2.0 maintenance BPSPs (EXP-STD group) demonstrated significantly greater daily and cumulative milk output, and greater milk output per minute spent pumping. Conclusions BPSPs that mimic the unique sucking patterns used by healthy term breastfeeding infants during the initiation and maintenance of lactation are more effective, efficient, comfortable and convenient than other BPSPs.

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