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Review
. 2023 May 12;23(1):237.
doi: 10.1186/s12887-023-04047-5.

Implementing an exclusive human milk diet for preterm infants: real-world experience in diverse NICUs

Jonathan R Swanson  1 , Amy Becker  2 , Jenny Fox  3 , Michael Horgan  4 , Russell Moores  3 , John Pardalos  5 , Joaquim Pinheiro  6 , Dan Stewart  7 , Tonya Robinson  8
Affiliations
Review

Implementing an exclusive human milk diet for preterm infants: real-world experience in diverse NICUs

Jonathan R Swanson et al. BMC Pediatr. .

Abstract

Background: Human milk-based human milk fortifier (HMB-HMF) makes it possible to provide an exclusive human milk diet (EHMD) to very low birth weight (VLBW) infants in neonatal intensive care units (NICUs). Before the introduction of HMB-HMF in 2006, NICUs relied on bovine milk-based human milk fortifiers (BMB-HMFs) when mother's own milk (MOM) or pasteurized donor human milk (PDHM) could not provide adequate nutrition. Despite evidence supporting the clinical benefits of an EHMD (such as reducing the frequency of morbidities), barriers prevent its widespread adoption, including limited health economics and outcomes data, cost concerns, and lack of standardized feeding guidelines.

Methods: Nine experts from seven institutions gathered for a virtual roundtable discussion in October 2020 to discuss the benefits and challenges to implementing an EHMD program in the NICU environment. Each center provided a review of the process of starting their program and also presented data on various neonatal and financial metrics associated with the program. Data gathered were either from their own Vermont Oxford Network outcomes or an institutional clinical database. As each center utilizes their EHMD program in slightly different populations and over different time periods, data presented was center-specific. After all presentations, the experts discussed issues within the field of neonatology that need to be addressed with regards to the utilization of an EHMD in the NICU population.

Results: Implementation of an EHMD program faces many barriers, no matter the NICU size, patient population or geographic location. Successful implementation requires a team approach (including finance and IT support) with a NICU champion. Having pre-specified target populations as well as data tracking is also helpful. Real-world experiences of NICUs with established EHMD programs show reductions in comorbidities, regardless of the institution's size or level of care. EHMD programs also proved to be cost effective. For the NICUs that had necrotizing enterocolitis (NEC) data available, EHMD programs resulted in either a decrease or change in total (medical + surgical) NEC rate and reductions in surgical NEC. Institutions that provided cost and complications data all reported a substantial cost avoidance after EHMD implementation, ranging between $515,113 and $3,369,515 annually per institution.

Conclusions: The data provided support the initiation of EHMD programs in NICUs for very preterm infants, but there are still methodologic issues to be addressed so that guidelines can be created and all NICUs, regardless of size, can provide standardized care that benefits VLBW infants.

Keywords: Advocacy; Cost; Exclusive human milk diet; Growth; Human milk fortifier; Implementation; NICU; Necrotizing enterocolitis; Preterm birth; Public policy.

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Conflict of interest statement

Dr. Swanson has received speaker’s honoraria from Mednax, Inc. and Prolacta Bioscience. All other authors declare no competing interests.

Figures

Fig. 1
Fig. 1
Nonsurgical and surgical NEC rates before and after EHMD implementation. Number of patients and years comprising each cohort are shown
Fig. 2
Fig. 2
Annualized costs and cost avoidance with EHMD use by center (anonymized). Total and itemized cost avoidance are shown. Information on other costs was not uniformly available at all centers
See this image and copyright information in PMC

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References

    1. Abrams SA, Schanler RJ, Lee ML, Rechtman DJ. Greater mortality and morbidity in extremely preterm infants fed a diet containing cow milk protein products. Breastfeed Med. 2014;9:281–285. doi: 10.1089/bfm.2014.0024. - DOI - PMC - PubMed
    1. Agostini C, Buonocore G, Carnielli VP, De Curtis M, Darmaun D, Decsi T, et al. Enteral nutrient supply for preterm infants: commentary from the European Society of Paediatric Gastroenterology, Hepatology and Nutrition Committee on Nutrition. J Pediatr Gastroenterol Nutr. 2010;50:85–91. doi: 10.1097/MPG.0b013e3181adaee0. - DOI - PubMed
    1. Assad M, Elliott MJ, Abraham JH. Decreased cost and improved feeding tolerance in VLBW infants fed an exclusive human milk diet. J Perinatol. 2016;36:216–220. doi: 10.1038/jp.2015.168. - DOI - PubMed
    1. Cristofalo EA, Schanler RJ, Blanco CL, Sullivan S, Trawoeger R, Kiechl-Kohlendorfer U, et al. Randomized trial of exclusive human milk versus preterm formula diets in extremely premature infants. J Pediatr. 2013;163:1592–1595.e1. doi: 10.1016/j.jpeds.2013.07.011. - DOI - PubMed
    1. Hair AB, Peluso AM, Hawthorne KM, Perez J, Smith DP, Khan JY, et al. Beyond necrotizing enterocolitis prevention: improving outcomes with an exclusive human milk–based diet. Breastfeed Med. 2016;11:70–74. doi: 10.1089/bfm.2015.0134. - DOI - PMC - PubMed

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