Donor Human Milk Use in Advanced Neonatal Care Units — United States, 2020

Approximately 50,000 infants are born in the United States each year with very low birthweight (VLBW) (<1,500 g).* Benefits of human milk to infants with VLBW include decreased risk for necrotizing enterocolitis, a serious illness resulting from inflammation and death of intestinal tissue that occurs most often in premature infants, especially those who are fed formula rather than human milk; late-onset sepsis; chronic lung disease; retinopathy of prematurity; and neurodevelopmental impairment (1). When mother’s own milk is unavailable or insufficient, pasteurized donor human milk (donor milk) plus a multinutrient fortifier is the first recommended alternative for infants with VLBW (2). CDC’s 2020 Maternity Practices in Infant Nutrition and Care (mPINC) survey was used to assess practices for donor milk use in U.S. advanced neonatal care units of hospitals that provide maternity care (3). Among 616 hospitals with neonatal intensive care units (level III or IV units),^† 13.0% reported that donor milk was not available for infants with VLBW; however, approximately one half (54.7%) reported that most (≥80%) infants with VLBW do receive donor milk. Donor milk availability for infants with VLBW was more commonly reported among hospitals with a level IV unit, higher annual birth volume, location in the Midwest and Southwest regions, nonprofit and teaching status, and those designated Baby-Friendly.^§ Addressing hospitals’ barriers to providing donor milk could help ensure that infants with VLBW receive donor milk when needed and help reduce morbidity and mortality in infants with VLBW (1,4).

The mPINC survey is a biennial census of all maternity care hospitals in the United States and territories to monitor practices and policies related to infant feeding. The survey is completed electronically by the persons most knowledgeable about the hospital’s practices related to infant nutrition. In 2020, hospitals with advanced neonatal care units (level II, III, or IV) were asked how many infants (<1,500 g and ≥1,500 g) receive donor milk at any time while in the unit: few (0%–19%), some (20%–49%), many (50%–79%), most (≥80%), or donor milk not available.

The prevalence of donor milk use was examined by unit level and infant weight^¶ (<1,500 g and ≥1,500 g). For infants weighing ≥1,500 g, analyses included hospitals with level II, III, or IV units. Analyses for infants weighing <1,500 g were restricted to hospitals with level III or IV units, where infants with VLBW typically receive care (3). Donor milk use among infants with VLBW was also examined by hospital characteristics: hospital type, teaching hospital status, Baby-Friendly designation, number of annual births, and region.** Availability was also examined by state or territory (state) by calculating the percentage of participating hospitals with a level III or IV neonatal intensive care unit in each state reporting that donor milk was available for infants with VLBW. Data were suppressed for states with fewer than five hospitals reporting. Descriptive analyses were conducted using SAS (version 9.4; SAS Institute). Because this is a census sample, SEs were not calculated, and statistical testing was not performed. This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.^††

In 2020, among 2,810 eligible maternity hospitals, 2,103 (74.8%) participated in mPINC. Among participating hospitals, 1,260 (59.9%) reported having an advanced neonatal care unit, including 642 (60.0%) level II, 528 (41.9%) level III, and 90 (7.1%) level IV units. Hospitals that did not answer the donor milk question were excluded, resulting in analytic samples of 616 hospitals with level III and IV units for infants <1,500 g and 1,256 hospitals with level II, III, or IV units for infants ≥1,500 g.

Among hospitals with level III or IV units, 13.0% reported that donor milk was not available for infants with VLBW, and 54.7% reported it was received by ≥80% of infants with VLBW (Table 1). Among hospitals with level II, III, or IV units, for infants weighing ≥1,500 g, 40.1% reported that donor milk was not available, and 15.9% reported that it was received by most of these infants. For both weight categories, donor milk was more commonly available and used at hospitals with level IV units than in those with level II or III.

Donor milk was reported to be unavailable for infants with VLBW in 11.6% of nonprofit, 16.0% of for-profit, and 17.1% of government or military hospitals (Table 2). Among teaching hospitals, 12.4% reported that donor milk was not available, and 53.3% reported it was received by ≥80% of infants with VLBW, compared with 16.9% and 64.0%, respectively, among nonteaching hospitals. Donor milk was not available for infants with VLBW in 11.1% of Baby-Friendly designated hospitals, compared with 14.3% of non–Baby-Friendly designated hospitals. Although donor milk was available for infants with VLBW in almost all (97.8%) level IV units (Table 1), its availability and use among hospitals with a level III unit varied by hospital size. Among the largest hospitals with a level III unit (≥5,000 annual births), 6.3% reported that donor milk was not available, and 40.6% reported it was received by ≥80% of infants with VLBW, compared with 44.0% and 36.0%, respectively, among the smallest such hospitals (<1,000 annual births). By region, nonavailability of donor milk for infants with VLBW ranged from 4.1% of hospitals in the Midwest to 23.8% in the Northeast, among those with level III or IV units.

Twenty-three U.S. states had at least 10 hospitals with a level III or IV neonatal intensive care unit, 13 had five to nine level III or IV hospitals, 15 had one to four level III or IV hospitals, and five had no hospital with level III or IV neonatal intensive care units participating in mPINC. Among the 36 states with five or more hospitals with a level III or IV unit, the statewide percentage of hospitals reporting donor milk availability for infants with VLBW ranged from 0% to 100% (median = 92.0%) (Figure). In 12 states (Alabama, Arkansas, Colorado, Indiana, Iowa, Massachusetts, Minnesota, New Mexico, Oregon, Utah, Washington, and Wisconsin), 100% of hospitals with level III or IV units reported donor milk was available for infants with VLBW; in seven states (Illinois, Maryland, North Carolina, Ohio, Pennsylvania, Texas, and Virginia), 90% to <100% of hospitals reported donor milk availability; in 10 states (Connecticut, Florida, Kentucky, Louisiana, Michigan, Mississippi, Nebraska, New Jersey, South Carolina, and Tennessee), 80% to <90% of hospitals reported donor milk availability; and in seven jurisdictions (California, Georgia, Kansas, Missouri, New York, Oklahoma, and Puerto Rico), <80% of hospitals reported that donor milk was available.

Corresponding author: Ellen O. Boundy, lwz9@cdc.gov, 770-488-4438.

¹Division of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease Prevention and Health Promotion, CDC.

References

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* SEs were not calculated, and statistical testing not performed, because Maternity Practices in Infant Nutrition and Care is a census sample.
^† Level II = special care nursery; level III = neonatal intensive care unit; level IV = regional neonatal intensive care unit. https://doi.org/10.1542/peds.2012-1999
^§ Hospitals reporting the percentage of infants who receive donor human milk at any time while cared for in the advanced neonatal care unit.
^¶ Row percentages might not sum to 100% because of rounding.

* SEs were not calculated, and statistical testing not performed, because Maternity Practices in Infant Nutrition and Care is a census sample.
^† Level II = special care unit; level III = neonatal intensive care unit; level IV = regional neonatal intensive care unit. https://doi.org/10.1542/peds.2012-1999
^§ Hospitals reporting the percentage of infants weighing <1,500 g who receive donor human milk at any time while cared for in a neonatal intensive care unit.
^¶ Row percentages might not sum to 100% because of rounding.
** Baby-Friendly USA is the accrediting body and national authority for the Baby-Friendly Hospital Initiative (BFHI) in the United States. BFHI is a global program to encourage the broad-scale implementation of steps to provide mothers with information, confidence, and skills necessary to successfully initiate and continue breastfeeding. https://www.babyfriendlyusa.org
^†† Regions defined by U.S. Department of Agriculture Food and Nutrition Service. https://www.fns.usda.gov/fns-regional-offices

FIGURE. Percentage of hospitals with level III or IV neonatal intensive care units reporting donor milk was available for infants weighing <1,500 g, by state* — Maternity Practices in Infant Nutrition and Care, United States, 2020

Abbreviations: AS = American Samoa; DC = District of Columbia; GU = Guam; MP = Northern Mariana Islands; PR = Puerto Rico; USVI = U.S. Virgin Islands.

* Includes all U.S. states, territories, and DC; data were suppressed when the sample was <5. The locations of 28 Human Milk Banking Association of North America–member milk banks are also noted.