The Payback from Improving Availability of Donor Human Milk for Premature Babies

CLAHRC WM is collaborating with the African Population Health Research Centre (APHRC) in the evaluation of donor milk banks in slums (informal settlements) in Kenya. The initiative is led by PATH,[1] which has had considerable success in establishing an altruistic donor service in South Africa. The donor milk is donated to hospital wards caring for premature infants.

There is excellent evidence that donor human milk is superior to ‘formula’ in babies whose mothers are unable to express breast milk. As a result of passive immunity, and also because it has nutritional properties that formula is not able to replicate, donor human milk reduces the risk of neonatal infection.[2] In particular, it reduces the dangerous condition of necrotising enterocolitis (NEC).[3][4] NEC can be fatal and may also require surgery that may have permanent consequences – particularly the ‘short bowel syndrome’. The decreased infection risk resulting from use of donor milk is associated with a measurable decrease in mean length of stay.[5]

One concern is that the mothers of infants who receive donor milk may be less likely to initiate breast feeding at a later date for psychological or physiological reasons. The evidence does not bear out this concern and, if anything, these mothers, perhaps inspired by the altruism of the donors, are more likely to breastfeed.[6][7] If so, this may be expected to augment the benefits of donor milk and also reduce the mother’s risk of developing breast cancer later in life.[8]

The benefits do not seem to end there. There is observational evidence, recently reinforced by a substantial study from Brazil,[9] that cognitive ability in later life is improved by human milk. There is a dose-response effect and the results remain after extensive statistical adjustment for confounders. There is also some experimental (RCT) evidence for a beneficial effect on IQ.[10] Improved IQ is correlated with earning power [11] and, we must assume, payback to society.[12]

To summarise the benefits of breastfeeding we offer the following Influence Diagram (Causal Pathway: Model):

CI - Improving Availability of Donor Human Milk Fig 1

A health economic analysis of promotion of breastfeeding for older children (not premature infants specifically) found that the intervention ‘dominated’ – reduced short-term benefits (less infection) and the contingent cost savings (reduced hospital stays) meant that interventions to promote breastfeeding are cost-saving, not just beneficial for health.[12][13]

There have been two studies of the cost-effectiveness of a donor milk service for premature babies. Both found that the service was cost-effective. The first study was based on a hypothetical baby who was very premature (28 weeks gestational age), rather than an observed mean intervention effect observed at the group level.[14] The calculated benefits might therefore be exaggerated. The second study was based on only 175 propensity scored low birth weight infants.[5] The risk of sepsis decreased with increasing dose of human milk, and total costs obtained from the hospital billing system were lower in proportion to the amount of human milk consumed. However, most infants received some human milk, so the infants could not be divided into a control and intervention population, and the above correlation between outcome and volume of donor milk consumed may have been confounded by factors that determine both access to human milk and sepsis, notwithstanding propensity scoring. Both the above studies were American.

Working with colleagues above, we propose a comprehensive health economic model that takes account of long-term outcomes and that can be populated with country-specific data. The base-case model will be populated with evidence from systematic reviews,[12][13] and we propose to use Bayesian techniques to ‘down weight’ observational evidence using the Turner and Spiegelhalter method.[15]

— Richard Lilford, CLAHRC WM Director
— Celia Taylor, Senior Lecturer

References:

  1. PATH. Models of milk banking in South Africa. Seattle, WA: PATH, 2011.
  2. Arslanoglu S, Ziegler EE, Moro GE. Donor human milk in preterm infant feeding: evidence and recommendations. J Perinat Med. 2010; 38: 347-51.
  3. Lucas A, Cole TJ. Breast milk and neonatal necrotising enterocolitis. Lancet. 1990; 336: 1519-23.
  4. Quigley M, McGuire W. Formula versus donor milk for feeding preterm or low birth weight infants. Cochrane Database Sys Revs. 2014; 4: CD002971.
  5. Patel AL, Johnson TJ, Engstrom JL, Fogg LF, Jegier BJ, Bigger HR, Meier PP. Impact of early human milk on sepsis and health-care costs in very low birth weight infants. J Perinatol. 2013; 33: 514-9.
  6. Arslanoglu S, Moro GE, Bellù R, Turoli D, De Nisi G, Tonetto P, Bertino E. Presence of human milk bank is associated with elevated rate of exclusive breastfeeding in VLBW infants. J Perinat Med. 2013; 41(2): 129-31.
  7. Vázquez-Román S, Bustos-Lozano G, López-Maestro M, et al. Clinical impact of opening a human milk bank in a neonatal unit. An Pediatr (Barc). 2014; 81(3): 155-60.
  8. Collaborative Group on Hormonal Factors in Breast Cancer. Breast cancer and breastfeeding: collaborative reanalysis of individual data from 47 epidemiological studies in 30 countries, including 50 302 women with breast cancer and 96 973 women without the disease. Lancet. 2002; 360: 187-95.
  9. Victora CG, Horta BL, Loret de Mola C, Quevedo L, Pinheiro RT, Gigante DP, Gonçalves H, Barros FC. Association between breastfeeding and intelligence, educational attainment, and income at 30 years of age: a prospective birth cohort study from Brazil. Lancet Glob Health. 2015; 3(4): e199-205.
  10. Horta BL, Victora CG. Long-term effects of breastfeeding: a systematic review. Geneva: World Health Organization. 2013
  11. US Environmental Protection Agency. The benefits and costs of the clean air act, 1970 to 1990, appendix G, lead benefits analysis. Washington, DC: Environmental Protection Agency, 1997.
  12. Renfrew MJ, Pokhrel S, Quigley M, et al. Preventing disease and saving resources: the potential contribution of increasing breastfeeding rates in the UK. UNICEF. 2012.
  13. Kramer MS & Kakuma R. Optimal duration of exclusive breastfeeding. Cochrane Database Sys Revs. 2012; 8: CD003517.
  14. Arnold LDW. The Cost-effectiveness of Using Banked Donor Milk in the Neonatal Intensive Care Unit: Prevention of Necrotizing Enterocolitis. J Hum Lact. 2002; 18(2): 172-7.
  15. Turner RM, Spiegelhalter DJ, Smith GCS, Thompson SG. Bias modeling in evidence synthesis. J R Stat Soc Ser A. 2009; 172: 21–47.
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