Changes in Donor Human Milk Use Among US Hospitals: 2018–2024

INTRODUCTION

Pasteurized donor human milk (PDHM) is recommended when mother’s own milk is unavailable or contraindicated.^1,2 Guidance prioritizes human milk for infants with very low birth weight (<1500 g) as it protects against complications, such as necrotizing enterocolitis.³ However, guidance on PDHM use among other newborns is lacking, particularly those in Level I neonatal care.⁴ Using 2018–2024 Maternity Practices in Infant Nutrition and Care (mPINC) data, we describe trends in DHM use among US hospitals by level of care and characteristics of hospitals that provided DHM.

METHODS

The mPINC survey is a biennial census of hospitals that provide maternity care in the United States reflecting practices and policies that are supportive of breastfeeding from the prior year.⁵ Hospitals with advanced neonatal care units (ANCUs; Levels II-IV)⁶ were asked how many newborns received DHM at any time while in an ANCU. All hospitals were asked how many supplemented breastfed (SBF) newborns in Level I care received DHM. Response options were not available/not offered, few (0%–19%), some (20%–49%), many (50%–79%), or most (≥80%).

We examined trends across 4 survey cycles for the prevalence of hospitals in which (1) newborns in ANCUs received DHM and (2) SBF newborns in Level I care received DHM. Using 2024 data, we stratified DHM use among SBF newborns in Level I care by hospital-level characteristics. Response rates were 70%–78% during these 4 survey cycles.⁷ Analyses were conducted in R version 4.3.2.

RESULTS

Among hospitals with ANCUs, the prevalence of hospitals in which newborns in ANCUs received DHM increased from 55.6% in 2018 to 72.9% in 2024 (Figure 1A). Among all hospitals, the prevalence of hospitals in which SBF newborns in Level I care received DHM increased from 25.2% in 2018 to 40.5% in 2024 (Figure 1B). Findings from sensitivity analyses, conducted among hospitals with complete data across all cycles, were similar for both trends (Supplemental Tables 1 and 2, respectively). Across all survey cycles, a higher prevalence of hospitals reported that “few” compared with hospitals that reported “some,” “many,” or “most” SBF newborns in Level I care received DHM.

FIGURE 1.

(A) Prevalence of hospitals with an ANCU (Level II = special care nursery; Level III = neonatal intensive care unit; and Level IV = regional neonatal intensive care unit⁴) where newborns in an ANCU received DHM (Centers for Disease Control and Prevention’s mPINC survey, 2018–2024; hospitals that responded to mPINC question on newborns that received DHM while in advanced neonatal care [Levels II, III, or IV] on the 2018 [n = 1220], 2020 [n = 1256], 2022 [n = 1196], or 2024 [n = 1264] mPINC surveys). Response options included donor milk not available, few (0%–19%), some (20%–49%), many (50%–79%), or most (≥80%) infants. During the 2018 and 2020 cycles, these options were stratified by infant weight (<1500 g or ≥1500 g). To account for this variation across cycles, for this analysis, hospital responses were dichotomized; hospitals that responded donor milk not available were coded as no and those responding few, some, many, or most infants received DHM were coded as yes. (B) Prevalence of hospitals where supplemented breastfed newborns in Level I care (well newborn nursery⁴) received DHM (Centers for Disease Control and Prevention’s mPINC survey, 2018–2024; hospitals that responded to mPINC question on supplemented breastfed newborns in Level I care that received DHM on the 2018 [n = 2042], 2020 [n = 2096], 2022 [n = 1989], or 2024 [n = 2056] mPINC surveys). Response options for the proportion of supplemented breastfed newborns in Level I care that received DHM included not offered at our hospital, few (0%–19%), some (20%–49%), many (50%–79%), or most (≥80%) infants.

Abbreviations: ANCU, advanced neonatal care unit; DHM, donor human milk; mPINC: Maternity Practices in Infant Nutrition and Care.

In 2024, among hospitals with a neonatal intensive care unit (Level III/IV), 60.5% of hospitals reported that SBF newborns in Level I care received DHM, and 39.5% of hospitals reported that these newborns did not receive DHM. Of hospitals with ANCUs in which SBF newborns in Level I care received DHM, 98.5% of hospitals reported that newborns in ANCUs also received DHM (Table 1). Compared with hospitals in which SBF newborns in Level I care did not receive DHM, hospitals where these newborns received DHM were more often urban (52.2% vs 81.3%), had a higher median of annual births (549 vs 1270) and mPINC scores (81 vs 88), and had a lower median of healthy, term breastfed newborns fed infant formula (35.0% vs 28.0%).

TABLE 1.

Characteristics of Hospitals by DHM Use for SBF Newborns in Level I Care^a (Centers for Disease Control and Prevention’s mPINC Survey, 2024)^b

Hospital Characteristics, mPINC	Hospitals Reporting: SBF Newborns in Level I Care Received DHM	Hospitals Reporting: SBF Newborns in Level I Care Did Not Receive DHM	Total
Hospital type, n (%)	n = 834	n = 1222	N = 2056
Government/military	73 (8.8)	183 (15.0)	256 (12.5)
Nonprofit, private	658 (78.9)	868 (71.0)	1526 (74.2)
For profit, private	103 (12.4)	171 (14.0)	274 (13.3)
Total live birthsc	n = 834	n = 1220	N = 2054
Median (Q1–Q3)	1270.0 (658.0–2356.0)	549.0 (246.5–1303.5)	800.0 (344.0–1757.0)
Total mPINC scorec,d	n = 833	n = 1222	N = 2055
Median (Q1–Q3)	88.0 (81.0–94.0)	81.0 (71.0–90.0)	84.0 (74.0–92.0)
Healthy, term breastfed newborns fed any infant formula (%)c,e	n = 828	n = 1214	N = 2042
Median (Q1–Q3)	28.0 (14.0–43.5)	35.0 (20.0–53.0)	30.0 (17.0–50.0)
Urban/rural,c,f n (%)	n = 832	n = 1219	N = 2051
Rural	156 (18.8)	583 (47.8)	739 (36.0)
Urban	676 (81.3)	636 (52.2)	1321 (64.0)
Newborns in advanced neonatal care (Levels II, III, or IV) received DHM,g n (%)	n = 663	n = 590	N = 1253
Yes	653 (98.5)	259 (43.9)	912 (72.8)
No	10 (1.5)	331 (56.1)	341 (27.2)

Abbreviations: DHM, donor human milk; mPINC, Maternity Practices in Infant Nutrition and Care; Q, quartile; SBF, supplemented breastfed.

^aLevel I = well newborn nursery; Level II = special care nursery; Level III = neonatal intensive care unit; and Level IV = regional neonatal intensive care unit.⁴

^bIncludes hospitals that reported on DHM use for SBF newborns in Level I care.

^cNumber of hospitals varied slightly from the total for some of the characteristics. Less than 1% were excluded owing to missing data.

^dmPINC scores measure hospital practices and policies supportive of breastfeeding.⁵ Possible scores range from 0 to 100, with higher scores indicating better maternity care practices and policies.

^eHospitals’ percentage of healthy, term breastfed newborns fed any infant formula was used to observe if DHM may be affecting or replacing infant formula use.

^fUrban or rural status was determined by categorizing the hospital’s zip code according to the US Department of Agriculture’s 2010 zip code–level Rural-Urban Commuting Area codes based on published methodology.⁸

^gAmong hospitals that reported on DHM use for SBF newborns in Level I care, 1256 hospitals reported having advanced neonatal care (Levels II, III, or IV) facilities. Of these hospitals, 3 were excluded because of missing data on DHM use for newborns in advanced neonatal care.

DISCUSSION

Our findings demonstrated an increase in the prevalence of hospitals reporting DHM use among newborns in ANCUs and SBF newborns in Level I care from 2018 to 2024. Nearly all hospitals with ANCUs reporting that SBF newborns in Level I care received DHM also reported that their newborns in ANCUs received DHM.

We found that DHM use for SBF newborns in Level I care might vary based on hospital characteristics, such as hospital size, urbanicity, and mPINC scores,⁷ which measure hospital practices and policies supportive of breastfeeding. Studies indicate that potential reasons for supplementation include infant weight loss⁹ and breastfeeding challenges¹⁰; however, additional research on health outcomes could inform guidance and provide evidence-based criteria for the allocation and use of DHM regardless of hospital characteristics.

Because the mPINC question on DHM use among newborns in Level I care only asked about SBF newborns, we could not assess the overall prevalence of DHM use at US hospitals. Neither could we compare DHM use among all newborns in Level I care against all newborns in ANCUs. We could not assess the reason for supplementation or barriers in DHM use; therefore, we could not quantify the frequency of appropriate supplementation. Additional guidance on DHM use in hospitals, specifically including newborns in Level I care, might improve newborn health by providing standardized and evidence-based criteria for the allocation of a limited resource.

ABBREVIATIONS

ANCU

advanced neonatal care unit

DHM

donor human milk

mPINC

Maternity Practices in Infant Nutrition and Care

PDHM

pasteurized donor human milk

SBF

supplemented breastfed