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# Paying for Milk:

February 28, 2018

In a recently released article in Pediatrics, Dr. Susan Trang and colleagues ask an important question: is donor milk for premature infants cost-effective? The cost of donor milk is high in comparison to preterm formula, and hence the authors’ question is meaningful for both healthcare consumers and payers.

In a recently released article in Pediatrics, Dr. Susan Trang and colleagues (10.1542/peds.2017-0737)Assistant Editor, Pediatrics ask an important question: is donor milk for premature infants cost-effective? The cost of donor milk is high in comparison to preterm formula, and hence the authors’ question is meaningful for both healthcare consumers and payers. However, breast milk, including donor human milk, has been well shown to reduce the risk of necrotizing enterocolitis (NEC), a disastrous, life-threatening complication of prematurity.1 Certainly parents and physicians want the best for each infant regardless of cost, but determining cost-effectiveness, or “bang for the buck” is an important transparency.

In this prospective randomized trial, 363 premature infants of mean gestational age of 27.7 weeks and mean birthweight of 996 grams were enrolled and randomized to receive either donor human milk or preterm formula if mother’s breastmilk was not sufficient in supply. Results from this trial have previously been published related to neurodevelopmental outcomes.2 The cost-effectiveness analysis described here by Dr. Trang and colleagues was pre-planned, and was conducted in tandem with the feeding trial. The authors clearly explain how costs associated with the study infants’ hospital care were calculated, primarily with a standardized accounting system: these included hospital stay costs (for example laboratory, medication and imaging costs), provider salaries, and indirect institutional costs allocated by length of the infant’s hospital stay. Post-discharge health and non-health costs were captured with a previously validated Family Health Economic Questionnaire filled out monthly; this questionnaire included the cost of parental missed work due to infant illness.

The cost of donor milk varies but is generally estimated as $3-5 per ounce, which includes both direct costs such as screening of donors, and processing and pasteurizing of breast milk, and indirect costs such as research and infrastructure. Both not-for profit (HMBANA - the Human Milk Banking Association of North America) and for-profit milk banks (Prolacta® Bioscience Inc.) supply donor human milk to hospitals. Dr. Trang et al use a cost of$4.95 (Canadian dollars) per ounce for donor human milk (with an additional $0.14 to fortify the donor milk so that protein, calories and micronutrients are sufficient), versus$0.13 dollars for bovine-based preterm formula. The difference in cost is striking. Many hospitals continue to receive preterm formula free from vendors, but this practice is not permitted for Baby Friendly designated birthing hospitals who must pay “fair market” price; including a cost for formula acknowledges the societal cost (and actual cost for Baby Friendly designated hospitals) of formula.3

At the end of the day, mean total cost from birth through 18 months corrected age was the same in both groups! However, the authors help us understand the difference between cost and cost-effectiveness by explaining the cost-effectiveness acceptability curve (CEAC) and the uncertainties associated with decision-making relative to cost – how many dollars are decision-makers willing to spend to prevent one case of NEC? For non-economists, this explanation is truly enlightening. And while total initial hospitalization charges were the same for both groups, what do you predict for the post-discharge period? Read on for this interesting result!

References:

1. Quigley M, McGuire W Formula versus donor breast milk for feeding preterm or low birth weight infants. Cochrane Database Syst Rev. 2014 Apr 22;(4):CD002971.

2. Unger S, Gibbins S, Zupancic J, O’Connor DL. DoMINO: Donor milk for improved neurodevelopmental outcomes. BMC Pediatrics. 2014;14:123.

3. Baby-Hospital USA. https://www.babyfriendlyusa.org/  (accessed 2/7/2018)

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