Impact of Optimized Breastfeeding on the Costs of Necrotizing Enterocolitis in Extremely Low Birthweight Infants

Abstract

Objective To estimate risk of NEC for ELBW infants as a function of preterm formula and maternal milk (MM) intake and calculate the impact of suboptimal feeding on NEC incidence and costs. Design We used adjusted odds ratios (aORs) derived from the Glutamine Trial to perform Monte Carlo simulation of a cohort of ELBW infants under current suboptimal feeding practices, compared to a theoretical cohort in which 90% of infants received at least 98% MM. Results NEC incidence among infants receiving ≥98% MM was 1.3%; 11.1% among infants fed only preterm formula; and 8.2% among infants fed a mixed diet (p=0.002). In adjusted models, compared with infants fed predominantly MM, we found an increased risk of NEC associated with exclusive preterm formula (aOR=12.1, 95% CI 1.5, 94.2), or a mixed diet (aOR 8.7, 95% CI 1.2-65.2). In Monte Carlo simulation, current feeding of ELBW infants was associated with 928 excess NEC cases and 121 excess deaths annually, compared with a model in which 90% of infants received ≥ 98% MM. These models estimated an annual cost of suboptimal feeding of ELBW infants of $27.1 million (CI $24million, $30.4 million) in direct medical costs, $563,655 (CI $476,191, $599,069) in indirect nonmedical costs, and $1.5 billion (CI $1.3 billion, $1.6 billion) in cost attributable to premature death. Conclusions Among ELBW infants, not being fed predominantly MM is associated with an increased risk of NEC. Efforts to support milk production by mothers of ELBW infants may prevent infant deaths and reduce costs.

Intestinal Barrier Maturation in Very Low Birthweight Infants: Relationship to Feeding and Antibiotic Exposure

“…Multiple retrospective and prospective randomized trials have demonstrated the beneficial effect of breast milk feeding on reducing the risk for NEC in preterm infants 33-38 . In a secondary analysis of the NICHD glutamine trial, Colaizy et al 5 determined a 12-fold increased risk of NEC associated with exclusive formula feeding compared with exclusive breast milk feeding in preterm neonates.…”

“…Although breast milk has been shown to be protective against NEC 4, 5 , postnatal antibiotic exposure may increase the risk for NEC 6, 7 . Intestinal barrier immaturity is the proximate cause of susceptibility to NEC in preterm neonates 8, 9 , but few preterm infants <30 wk gestation have been included in prior studies of intestinal permeability (IP) 10-15 and the impact of current feeding practices and antibiotic exposures on intestinal barrier maturation in the extremely preterm population is unknown.…”

Microbial Biomarkers of Intestinal Barrier Maturation in Preterm Infants

“…In this study, early exclusive breast milk feeding and low antibiotic exposure was associated with the presence of members of Clostridiales in the stool microbiota of preterm infants. We have previously observed these two factors are associated with improved IP in preterm infants 16 , which has been shown to be critically protective against NEC 35 . This observation emphasizes the importance of factors such as clinical administration of nutritional supplement and limiting exposure to antibiotic in neonatal care units.…”

Improving Access to Medical Lactation Support and Counseling: Building the Case for Medicaid Reimbursement

“…Our calculations modeled the potential health savings associated with reaching Healthy People 2020 breastfeeding objectives, assuming that increasing access to lactation support services for low-income mothers will significantly improve breastfeeding rates. These ambitious assumptions are grounded in models used both nationally (Bartick & Reinhold, 2010; Colaizy et al, 2016) and by other states (Ma et al, 2013), as well as in evidence from previous interventions showing the effectiveness of IBCLC services for increasing exclusive breastfeeding and breastfeeding intensity in low-income populations (Bonuck et al, 2014; Su et al, 2007). …”