An exclusive human milk diet for very low birth weight newborns-A cost-effectiveness and EVPI study for Germany

Economic evaluations of human milk for very preterm infants: a systematic review

Background

Very preterm infants are highly vulnerable to complications, imposing a significant economic burden on healthcare systems. Human milk has protective effects on these infants, but there is no systematic review on its economic impact.

Objective

We conducted a comprehensive review of studies assessing the economic evaluations of human milk for very preterm infants.

Methods

Our literature search covered PubMed, Embase, the Cochrane Library, and Web of Science. Two reviewers independently extracted data on economic evaluations and assessed study quality using the Pediatric Quality Appraisal Questionnaire (PQAQ).

Results

Fourteen studies of moderate quality, conducted in the United States, Germany, and Canada, met the inclusion criteria. However, the studies analyzed had notable variations and shortcomings. The majority of these studies (n = 11) performed economic evaluations from a healthcare system perspective, utilizing cost-consequence analysis (n = 6) up to the point of neonatal discharge (n = 11). All human milk interventions indicated cost-effective or cost saving results; only a minority included discounting (n = 2).

Conclusion

This systematic review suggests that economic evaluation of human milk for very preterm infants is an expanding area of research. Human milk for very preterm infants offers substantial economic advantages during neonatal intensive care unit hospitalization. Standardized and high-quality studies are needed to determine the cost-effectiveness of human milk for very preterm infants in the future.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO, identifier (CRD42024539574).

Association between body mass index at birth and neonatal health outcomes in preterm infants: A retrospective analysis

BACKGROUND

Studies on how birth body mass index (BMI) affects health outcomes in preterm infants are relatively limited.

AIM

To analyze the association between BMI at birth and neonatal health outcomes in extremely low and very low birth weight preterm infants in China.

METHODS

Used data from the Chinese Premature Infant Informatization Platform (2022-2023). Preterm infants were categorized based on their birth BMI z-scores into three groups: low BMI group (< -2), normal BMI group (-2 to 2) and high BMI group (>2). The relationship between BMI and neonatal health outcomes was then analyzed.

RESULTS

The final analysis included 1662 extremely low and very low birth weight preterm infants. The results indicated that low BMI was significantly associated with an increased risk of respiratory distress syndrome (RDS) (AOR 1.61, 95% CI 1.31-2.30), bronchopulmonary dysplasia (BPD) (AOR 1.34, 95% CI 1.00-1.80) and necrotizing enterocolitis (NEC) (AOR 1.57, 95% CI 1.01-2.42). High BMI was significantly associated with an increased risk of RDS (AOR 1.60, 95% CI 1.05-2.45).

CONCLUSIONS

BMI at birth is significantly associated with the risks of RDS, BPD and NEC in ELBW and VLBW, highlighting the importance of monitoring BMI as an additional risk predictor in a population of neonates already at high risk for adverse outcomes.

Exclusive Human Milk Diets and the Reduction of Necrotizing Enterocolitis

BACKGROUND

Necrotizing enterocolitis (NEC) is common in preterm infants, especially infants less than 32 weeks gestation. Mortality from NEC is 7% and occurs in 1 out of 1000 preterm infants. Studies have shown the efficacy of an exclusive milk from mother diet in decreasing rates of NEC and associated mortality.

PURPOSE

To evaluate the effectiveness of an existing exclusive human milk diet (EHMD) protocol on the incidence of NEC in extremely premature infants. EHMD, for the purposes of this project is defined as breast milk of mother, with or without human milk-based fortifier.

METHODS

A single-center retrospective quasi-experimental study. The sample included 201 infants born less than 32 weeks gestation, weighing less than 1250 grams, small for gestational age (SGA) and with low Apgar scores. Outcomes measured included incidences of NEC, mortality, and co-morbidities in infants pre- and postinitiation of an EHMD protocol.

RESULTS

Just 4.8% of the EHMD group had a NEC diagnosis compared to 10.5% of the bovine-based (BOV) group. There was a 1% mortality rate of the EHMD group as compared to 6% in the BOV group. The EHMD group had a statistically significant greater weight gain during hospitalization as compared to infants fed BOV ( P = < .05).

IMPLICATIONS FOR PRACTICE AND RESEARCH

Neonatal intensive care units should consider EHMDs for use in this infant population. Future research is needed to support dissemination of the use of EHMD as standard of practice.

A budget impact analysis of exclusive human milk diet in very low birth weight infants in United Arab Emirates

INTRODUCTION

Very low birth weight (VLBW) infants have the highest rate of neonatal intensive care unit (NICU) admissions owing to the higher comorbidities associated with premature birth and long hospital stays. VLBW infants fed a bovine (BOV)-based diet have higher mortality rates, necrotizing enterocolitis (NEC), late-onset sepsis (LOS), and other comorbidities than those fed 100% human milk-based products. This study aims to evaluate the budgetary impact of adopting an exclusive human milk diet (EHMD) instead of a BOV-based diet in VLBW infants from Al-Ain Hospital, Sheikh Shakhbout Medical City, and Dubai Health Authority (DHA) in the United Arab Emirates (UAE).

METHODS

We use a decision-tree model to estimate the budget impact of adopting EHMD versus the current local practice (BOV) over 5 years. Patients enter the tree model and have a probability of transitioning to one of the following mutually exclusive health states: NEC, which may be treated medically or surgically; LOS, NEC, and LOS; or neither NEC nor LOS. Depending on the feeding strategy, infants in the aforementioned health states are likely to develop any of the following complications: retinopathy of prematurity, bronchopulmonary dysplasia, or short bowel syndrome. The model accounts for the costs associated with diet, management of health states and complications, and the follow-up period.

RESULTS

Al-Ain Hospital saved United Arab Emirates Dirham (AED) 3.3 million ($1.4million) in the first year of the EHMD feeding arm and AED 16.6 million ($7.1million) over the course of 5 years. In comparison to Sheikh Shabout Medical City and DHA, AED 36.7 million ($15.8million) and AED 24 million ($10.3million) were saved over 5 years, respectively, with AED 7.3 million ($3.1million) and 4.8 million ($2million) saved in the first year. The estimated pooled results across the three institutions were AED 5.1 million ($2.2million) and AED 25.7 million ($11million) savings in the first year and over 5 years, respectively.

CONCLUSION

Implementing the EHMD feeding scheme in VLBWs that has significant clinical benefits has resulted in substantial budget savings from the payer's perspective in the UAE owing to fewer comorbidities associated with premature birth and shorter hospital stays. It is highly recommended for the Emirati health care settings to evaluate the real-world neonatal complication rates.

Costs and cost-effectiveness of treatment setting for children with wasting, oedema and growth failure/faltering: A systematic review

This systematic review aimed to address the existing evidence gaps, and guide policy decisions on the settings within which to treat infants <12 months of age with growth faltering/failure, and infants and children aged <60 months with moderate wasting or severe wasting and/or bilateral pitting oedema. Twelve electronic databases were searched for studies published before 10 December 2021. The searches yielded 16,709 records from which 31 studies were eligible and included in the review. Three studies were judged as low quality, whilst 14 were moderate and the remaining 14 were high quality. We identified very few cost and cost-effectiveness analyses for most of the models of care with the certainty of evidence being judged at very low or low. However, there were 17 cost and 6 cost-effectiveness analyses for the initiation of treatment in outpatient settings for severe wasting and/or bilateral pitting oedema in infants and children <60 months of age. From this evidence, the costs appear lowest for initiating treatment in community settings, followed by initiating treatment in community and transferring to outpatient settings, initiating treatment in outpatients then transferring to community settings, initiating treatment in outpatient settings, and lastly initiating treatment in inpatient settings. In addition, the evidence suggested that initiation of treatment in outpatient settings is highly cost-effective when compared to doing nothing or no programme implementation scenarios, using country-specific WHO GDP per capita thresholds. The incremental cost-effectiveness ratios ranged from $20 to $145 per DALY averted from a provider perspective, and $68 to $161 per DALY averted from a societal perspective. However, the certainty of the evidence was judged as moderate because of comparisons to do nothing/ no programme scenarios which potentially limits the applicability of the evidence in real-world settings. There is therefore a need for evidence that compare the different available alternatives.

LioNeo project: a randomised double-blind clinical trial for nutrition of very-low-birth-weight infants

We assessed the effectiveness of lyophilised banked human milk (HM) as a fortifier to feed very-low-birth-weight infants (VLBWI). This study aimed to evaluate the safety and tolerability of HM with HM lyophilisate as an additive compared with the standard additive (cows' milk protein). In this phase I double-blind randomised controlled clinical trial, set in the intensive and intermediate care units of a tertiary hospital, forty VLBWI were enrolled and allocated into two groups: HM plus HM lyophilisate (LioNeo) or HM plus commercial additive (HMCA). The inclusion criteria were preterm infants, birth weight 750-1500 g, small or adequate for gestational age, exclusively receiving donor HM, volume ≥ 100 ml/kg per d and haemodynamically stable. Participants were followed up for 21 consecutive days. The primary outcome measures were necrotising enterocolitis (NEC), late-onset sepsis (LOS), death, gastrointestinal (GI) bleeding or perforation, diarrhoea, regurgitation, vomiting and abdominal distension. The LioNeo and HMCA groups had similar weights at baseline. The regression models showed no differences between the groups in terms of the primary outcomes. Diarrhoea, GI perforation, NEC and LOS were absent in the LioNeo group (one LOS and one NEC in the HMCA group). Multiple regression analysis with the total volume of milk as a covariate did not show significant differences. The lyophilisation of donor HM was considered safe and tolerable for use in stable haemodynamically VLBWI.

Impact of a Standardized Nutrition Bundle Including Donor Human Milk on Hospital Outcomes in Very Low Birth-Weight (VLBW) Infants in a Safety-Net Hospital

BACKGROUND

Standardized protocols have been shown to reduce clinical practice variation and improve patient outcomes.

PURPOSE

To measure the impact of a standardized nutrition bundle inclusive of donor human milk (DHM) on hospital outcomes of very low birth-weight (VLBW) infants in a safety-net hospital.

METHODS

The study used the Model for Improvement methodology to drive improvement in practice. Outcome measures consisted of necrotizing enterocolitis (NEC), mortality, growth at 36 weeks' postmenstrual age and discharge, as well as volume and type of milk consumption during hospitalization.

FINDINGS

NEC rate decreased from 16.67% in the control group to 6.78% in the standardized nutrition bundle group (P = .07). Similarly, there was significant reduction in mortality with the bundled intervention (15.6% in the control group vs 1.6% in the nutrition bundle group; P = .006). Time to first (15 vs 27.5 hours of life; P < .001) and full-volume enteral feeding (8.5 vs 10 days; P = .086) were reduced in the standardized nutrition bundle group compared with the control group. The human milk volume almost doubled with the intervention.

IMPLICATIONS FOR PRACTICE

Our standardized nutrition bundle protocol inclusive of DHM resulted in lower NEC rates and reduced mortality. The implementation of the DHM program proved to be cost-effective and saved lives. Our findings may help guide development of a structured approach to nutrition protocols inclusive of DHM that can be adapted by other units located in safety-net hospitals.

IMPLICATIONS FOR RESEARCH

Future research on ethnic and racial barriers to access and affordability of DHM is warranted and much needed.

An economic analysis of the cost of survival of micro preemies: A systematic review

OBJECTIVE

This study aimed to systematically review the current literature on the economic costs of micro preemie as well as evidence on the cost-effectiveness of interventions to improve outcomes for micro preemie babies with a birth weight of ≤500 g.

METHOD

We searched MEDLINE, CINAHL, Scopus, ECONLIT, Business Source Premier and Cochrane Library for studies reporting costs of micro preemie from January 2000. Costs were inflated to 2019 United States dollars (US$). All full-text articles were assessed for eligibility and a quality assessment of included articles was conducted using the Drummond and the Larg and Moss checklists.

RESULTS

The search identified three studies that met the inclusion criteria; two cost-of-illness studies and one cost-effectiveness study. Across studies, the mean healthcare spending per micro preemie survivor (in 2019 US$) ranged from US$61,310 (birth admission) to US$263,958 (inpatient and outpatient for the first six months of life). One modelling study reported exclusive human milk diet for micro preemies at birth was more cost-effective compared to the standard approach with cow milk diet from the third-party payer and societal perspectives.

CONCLUSION

Despite significant advances in perinatal care and expanded access to life-saving equipment to improve survival outcomes of micro preemie, there remains a paucity of research on economic costs associated with these babies. No study has utilised quality-adjusted life-years as an outcome measure. Given the chronic conditions and long-term neurologic disability associated with micro preemie survivors, an estimate of the lifetime cost to the individual, healthcare providers and society would provide a benchmark of the potential cost-savings that could accrue from cost-effective interventions to improve the survival rate of micro preemies.

The infant microbiome and implications for central nervous system development

Neurodevelopmental impairment remains a significant morbidity in former very low birth weight premature infants. There is increasing evidence the microbiome affects neurodevelopment but mechanistic causes are largely unknown. There are many factors which affect the developing microbiome in infants including mode of delivery, feeding, medications, and environmental exposures. The overall impact of these factors may differ between premature and term infants. The microbiome and brain have well recognized bidirectional communication pathways via neural, hormonal, and immunologic mechanisms. Understanding the interplay between these different pathways has been possible with the use of animal models, particularly germ-free mice. The intricate relationship between the microbiome and the brain remains a research priority not only to improve the care, but to also improve the long-term neurodevelopmental outcomes in this vulnerable population.