Impact case study database

Impact on policy statements, guidelines, toolkits and care pathways

Research undertaken at York has informed international and national guidelines on enteral feeding strategies for very preterm and VLBW infants.

Three sets of World Health Organisation (WHO) guidelines cite York research:

• “Donor Human Milk for Low Birth Weight Infants”;

• “Feeding of Very Low Birth Weight Infants”; and

• “Standard Formula for Low Birth Weight Infants”.

All are subsets of the WHO’s guidance on feeding of low birth weight infants [1].

Research output [B] is cited as the underpinning evidence for recommending that VLBW infants “ who cannot be fed mother's own milk should be fed donor human milk [in] settings where safe and affordable milk-banking facilities are available or can be set up”. Seven outputs authored by McGuire (including **[D][E][F]**) are cited as informing feeding guidelines for VLBW infants, including specific recommendations on the rate of enteral feeding and the use of nutrient fortifiers.

York research is cited in other national and international guidelines and policy documents by the American Academy of Pediatrics (AAP), the Canadian Consensus Group (CCG), and the European Association of Perinatal Medicine (EAPM) [2]:

• The AAP 2017 policy statement cites output [B] in recommending the use of donor human milk: “ recent studies support health benefits for its use in [VLBW] infants, especially in decreasing rates of necrotizing enterocolitis”.

• The CCG 2015 guidelines refer to output [E] to underpin key recommendations for VLBW infants, including to “ start trophic feeds preferably within 24h of life”; and “… if the feeds are tolerated for around 2-3 days, consider increasing faster”.

• The EAPM 2017 consensus guidelines recommend early initiation of human milk feeds, and their rapid advancement, for VLBW infants, stating that “ there is no evidence of increased NEC [necrotising enterocolitis] with early initiation of feeds or advancing feeds more rapidly”, based on McGuire’s finding [C][E]. Output [B] is cited to support the recommendation that “ donor breast milk is better than formula as it reduces the risk of necrotising enterocolitis”.

Impact on training and education

Through its underpinning of WHO and other guidance and policy statements, York research has informed training and education in enteral feeding for very preterm and VLBW infants in the UK and internationally, leading to the wider use of donor human milk and progressive enteral feeding. For example:

• The Interpractice 21st project (Oxford Maternal and Perinatal Health Institute) provides training for healthcare professionals to promote the best international standards in nutrition for preterm infants. The online module, “Feeding Recommendations for the Routine Care of Preterm Infants”, available in English, Spanish, Italian, Russian and Portuguese, cites output [E] as the evidence for recommendations on the initiation, advancement, and volume and frequency of enteral feeds [3].

• The European Standards of Care for Newborn Health, a practical standards-based resource for neonatal healthcare practitioners, cites outputs [B][C][E] in its advice on establishment of enteral feeding in preterm infants [4].

Impact on adoption and practice

The volume and use of donor human milk, and establishment of donor milk banks, has increased substantially in the UK and internationally during the past decade [5]. For example, Human Milk Banking Association of North America data indicate an expansion from 16 non-profit milk banks in 2013 to 30 as of 2020. Collectively, these processed about 85,000L of milk in 2013, rising to ~210,000L in 2019 [5]. The expansion is predicated on research including the York Cochrane reviews, and the WHO guidance that draw on these. Milk banks internationally base their existence and practice on the WHO guidance, as evidenced in sources such as the Australian Government’s healthcare resource pages, and official recommendations for the adoption of milk banks in Spain which cite both the recent WHO guidance and York research [5]. The Health Scotland 2017 report for NHS practitioners and policy makers notes that “ access to donor breast milk in all neonatal units has resolved some of the issues of making breast milk equally available to all babies who need it” [5].

Further evidence of impact in neonatal care facilities is provided by recent studies in North America. A quality improvement project in Massachusetts (USA) that examined the effect of newly-introduced feeding regimens on growth for very preterm infants cites outputs [C] and [E] as underpinning two of its key elements: “earlier initiation of trophic feeds [and] accelerated daily feeding” [6]. A study examining the expansion in US neonatal units using donor human milk for supplemental feeding of very preterm or VLBW infants (74% increase since 2011) cited output [B] as the unpinning evidence that allowed practitioners to become more confident in recommending adopting this practice [7a].

Impact on patient outcomes and cost savings

The changes in practice based on York research have improved care and outcomes for very preterm and VLBW infants. The Massachusetts initiative concluded that the new enteral feeding regimens reduced time to establish feeds and reduced central vascular catheter use, a major risk factor for infection and sepsis in very preterm infants [6]. Another US study showed that “ a progressive standardized, evidence-based feeding protocol was associated with improved growth without increased risk for necrotizing enterocolitis” in VLBW infants [7b]. In the UK, the Human Milk Foundation, a charitable umbrella organisation for NHS milk banks, connects increased use of donor human milk with reduction in necrotising enterocolitis and the saving of preterm infants’ lives [5].

Cost savings may be associated with adopting enteral feeding regimens informed by the York reviews [8]. The Massachusetts study concluded that “ the change in practice also resulted in cost savings” because infants spend a shorter time spent in neonatal intensive care units [6]. Economic modelling from a UK NHS perspective suggests that interventions to reduce the use of formula for feeding preterm infants are likely to achieve substantial cost savings for the UK NHS (lifetime quality-adjusted life year gain >10,000), principally by reducing rates of necrotising enterocolitis, sepsis, and neurodevelopmental impairment [9]. In Southern Africa, analysis suggests that donor human milk is a highly cost-effective intervention for very preterm infants, costing ("worst case") USD619 per Disability Adjusted Life Year averted. This analysis concluded that there is a “ compelling argument to increase the supply of donor milk in middle-income countries” [10].