Quality indicators for human milk use in very low-birthweight infants: are we measuring what we should be measuring?

OBJECTIVE: The objective of this study was to compare the currently used human milk (HM) quality indicators that measure whether very low-birthweight (VLBW; <1500 g birthweight) infants 'ever' received HM and whether they were still receiving HM at discharge from the neonatal intensive care unit (NICU) to the actual amount and timing of HM received. STUDY DESIGN: This study used data from a large NIH-funded cohort study and calculated whether VLBW infants ever received HM (HM-Ever) and of these infants, the percentage who were still receiving HM at NICU discharge (HM-DC). Then, the HM-DC indicator (exclusive, partial and none) was compared with the amount and timing of HM feedings received by these same infants. RESULT: Of the 291 VLBW infants who met inclusion criteria, 285 received some HM (HM-Ever=98%). At NICU discharge (HM-DC), 24.2, 15.1 and 60.7% were receiving exclusive, partial and no HM, respectively. Of the 60.7% infants with no HM-DC, some had received higher amounts of HM during the NICU hospitalization than infants categorized as exclusive and partial for HM-DC. Of the infants with no HM-DC, 76.8 and 59.7% had received exclusive HM during the days 1-14 and days 1-28 exposure periods, respectively. CONCLUSION: The average daily dose (HM-DD; in ml kg(-1) d(-1)) and cumulative percentage (HM-PCT; as % of cumulative enteral intake) of HM feedings were sufficient to significantly reduce the risk of multiple morbidities, including late-onset sepsis, necrotizing enterocolitis, neurocognitive delay and rehospitalization, in the majority of the VLBW infants who were discharged with no HM-DC. Quality indicators that focus on the amount and timing of HM feedings in the NICU should be added to the HM-Ever and HM-DC measures.

Impact of early human milk on sepsis and health-care costs in very low birth weight infants.

OBJECTIVE: To study the incidence of sepsis and neonatal intensive care unit (NICU) costs as a function of the human milk (HM) dose received during the first 28 days post birth for very low birth weight (VLBW) infants. STUDY DESIGN: Prospective cohort study of 175 VLBW infants. The average daily dose of HM (ADDHM) was calculated from daily nutritional data for the first 28 days post birth (ADDHM-Days 1-28). Other covariates associated with sepsis were used to create a propensity score, combining multiple risk factors into a single metric. RESULT: The mean gestational age and birth weight were 28.1 ± 2.4 weeks and 1087 ± 252 g, respectively. The mean ADDHM-Days 1-28 was 54 ± 39 ml kg(-1) day(-1) (range 0-135). Binary logistic regression analysis controlling for propensity score revealed that increasing ADDHM-Days 1-28 was associated with lower odds of sepsis (odds ratio 0.981, 95% confidence interval 0.967-0.995, P=0.008). Increasing ADDHM-Days 1-28 was associated with significantly lower NICU costs. CONCLUSION: A dose-response relationship was demonstrated between ADDHM-Days 1-28 and a reduction in the odds of sepsis and associated NICU costs after controlling for propensity score. For every HM dose increase of 10 ml kg(-1) day(-1), the odds of sepsis decreased by 19%. NICU costs were lowest in the VLBW infants who received the highest ADDHM-Days 1-28.

Mothers' performing creamatocrit measures in the NICU: accuracy, reactions, and cost.

OBJECTIVE: To determine whether mothers of infants in the neonatal intensive-care unit could be taught to perform creamatocrits (CRCTs) accurately on own mothers' milk (OMM). These mothers' reactions to performing CRCTs also were measured. SAMPLE: Twenty-six mothers and four advanced-practice nurses (RNs) participated in this study. DESIGN: For Phase One of this blinded trial, mothers were taught to perform the CRCT by one of the two instructional RNs. For Phase Two, mothers and one of the two validation RNs performed CRCTs simultaneously and independently on the same OMM sample, and the mother completed a Maternal Reactions questionnaire. RESULTS: Mothers' CRCT measures were highly accurate. The mean absolute difference between RNs' and mothers' CRCTs was 0.69%, with 50% and 84.6% of these differences, respectively, < or = 0.5% and < or = 1.0% CRCT. A strong linear correlation was noted between RNs' and mothers' CRCTs. Ninety-six percent of the mothers reported that the CRCT was easy to learn, they felt comfortable performing the procedure, and it made them feel more involved in infant care. A mean of 23.6 minutes was spent teaching the mother to perform CRCT, a figure that reflects the cost-effectiveness of the approach. CONCLUSION: Mothers can be taught to perform CRCTs accurately and easily on their OMM. This practice exemplifies high quality, cost-effective care that maximizes maternal involvement and satisfaction.

Influence of increased survival in very low birth weight, low birth weight, and normal birth weight infants on the incidence of sudden infant death syndrome in the United States: 1985-1991.

OBJECTIVE: To examine the relationship between infant survival and the rates sudden infant death syndrome (SIDS) in very low birth weight (VLBW), low birth weight (LBW), and normal birth weight (NBW) infants from 1985 to 1991. METHODS: The National Center for Health Statistics Birth Cohort Linked Birth/Infant Death Data Sets were used to determine birth weight, age at death, and cause of death for US-born singleton infants with birth weights of 500 g or more. RESULTS: Increasing infant and postneonatal survival rates were greatest in VLBW infants. In contrast, SIDS rates did not change in VLBW infants (3.66 to 3.69; P = .70) but declined in both LBW (3.51 to 3.32; P = .041) and NBW (1.07 to 1.03; P = .008) infants. Postneonatal SIDS rates (per 1000 neonatal survivors) did not change in VLBW (4.93 to 4.58; P = .58) or LBW (3.36 to 3.22; P = .07) infants but declined in NBW infants (1.00 to 0.97; P = .018). Although there were differences among the slopes of survival rates, there was no statistical evidence of differences in the slope of SIDS rates among the three groups. CONCLUSIONS: The marked increase in survival of VLBW infants increased the pool of babies at potential risk for SIDS. VLBW infants' SIDS rates have not changed while they have declined in NBW and LBW infants.

The cost of prematurity: a case-control study of twins vs singletons.

OBJECTIVES: This study evaluated the extent to which morbidity and costs at birth were associated with plurality, gestational age, and birth-weight with a sample of twins from a large urban hospital. METHODS: Each twin infant was matched to two singleton infants (control [ctrl]-singletons) for payor status and race, and to one singleton infant (gestation [ga]-singleton) for payor status, race, and gestational age; after exclusion of infants who were transferred, the study population included 111 twins, 242 ctrl-singletons, and 106 ga-singletons. Data were stratified by five gestational categories and compared across study groups. Outcomes included birthweight, neonatal diagnoses, infant length of stay, infant costs per day, and total infant and total birth costs. RESULTS: Total birth costs ranged from $280,146 at 25 to 27 weeks to $9,803 at 39 to 42 weeks, decreasing with advancing gestation to means of $88,891 (twins), $43,041 (ga-singletons), and $9,326 (ctrl-singletons). Twins did not differ from either group of singletons in prematurity-related diagnoses, length of stay, or costs until after 34 weeks' gestation. CONCLUSIONS: In this sample, prematurity, not plurality, was the predominant cost factor at birth. Compared with singletons, twins experienced increased morbidity and associated costs after 38 weeks' gestation.