Advocating for donor milk access in Medicaid: bringing equity to the neonatal intensive care unit

Of all the complications of prematurity, necrotizing enterocolitis (NEC) is among the most catastrophic, causing significant mortality and short- and long-term morbidity. NEC affects ~5–10% of very low birthweight (VLBW) infants ≤1500 g and the incidence is inversely proportional to gestational age.¹ Overall mortality is ~24%, and NEC accounts for one in ten neonatal deaths. Mortality more than doubles to 51% in infants with birthweights ≤1000 g who require surgical intervention.^1,2,3,4,5 Survivors are at risk for intestinal failure, short gut syndrome, liver disease, and neurodevelopmental disability.^1,6,7 Taking into account the increased need for medical and surgical intervention in the neonatal period and continued healthcare utilization beyond the neonatal intensive care unit (NICU), NEC is associated with a significant increase in direct healthcare costs.^8,9 Care for an infant with surgical NEC may cost >$300,000.¹⁰ Given the clinical burden, patient impact, and strain on healthcare resources, NEC has long been a focus of pediatric research. Leveraging the primary role of inflammation in NEC, two articles in this issue explore novel strategies to reduce the impact of the disease. In an experimental mouse model of NEC, Li et al. demonstrate that pretreatment with an intraperitoneal amniotic fluid stem cell preparation attenuates interleukin-6 messenger RNA expression in the distal ileum and reduces the severity of histopathological injury, potentially by promoting cell proliferation of the epithelium.¹¹ Within a larger prospective study of VLBW infants across two centers, Tetreault et al. analyzed eight cases of stage 3 NEC compared to 14 matched, non-NEC controls, identifying a combination of potential stool biomarkers with 80% sensitivity and 70% specificity in predicting the development of NEC within 10 days.¹²

Although the pathogenesis of NEC is not fully understood, many strategies and therapies for the prevention of NEC have been explored. A human milk-based diet, in the form of mother’s own milk, donor human milk and/or human milk-based fortification shows the largest potential for clinical impact and cost savings. Pasteurized donor human milk’s (DBM) protective effect against NEC may also be dose-dependent.^13,14 Reducing exposure to artificial formula reduces the risk of NEC by almost 50%.^13,14 Multiple studies have demonstrated the benefits of DBM in reducing NEC in VLBW infants and increasing the eventual use of maternal breast milk.^{14,15,16,17,18} Even in settings where the mother’s own milk use is high, DBM does not incur extra overall costs, although savings may take up to 18 months to be realized.³ Within one state collaborative, greater availability of DBM resulted in a 10% increase in maternal breast milk feeding.¹⁹ Use of DBM may also decrease feeding intolerance and thus the length of stay and need for total parenteral nutrition, but may result in the risk of decreased short-term in-hospital weight gain and potentially reduced cognitive performance compared to maternal breastmilk-fed infants or those who also receive preterm formula.^20,21

Log in or create a free account to read this content

Gain free access to this article, as well as selected content from this journal and more on nature.com

Access through your institution

or

Sign in or create an account

Continue with Google

Continue with ORCiD