NICU by the Numbers

Infants Receiving Human Milk at Discharge Varies Internationally


Breastfeeding and human milk provide many significant short-term and longer-term benefits to infant health and development. The American Academy of Pediatrics (2) and The American College of Obstetricians and Gynecologists (3) recommend human milk for all infants with pasteurized donor milk, rather than premature infant formula, as the preferred alternative if a mother is unable to provide an adequate volume.


Vermont Oxford Network members submitted standardized data for very low birth weight infants who were 401 to 1500 grams or 22 weeks 0 days to 29 weeks 6 days gestational age at birth and admitted to member hospitals within 28 days of birth. The population included 406,309 VLBW infants admitted to 1113 NICUs from 2009 to 2016 receiving any enteral feedings during the 24 hour period before discharge. We report rates of exclusive human milk and human milk in combination with fortifier or formula.

The percentage of infants receiving any human milk has been increasing since 2009. However, the percentage of infants who received any human milk at discharge varies by region. Among North America members, 51% of infants were discharged on human milk compared to 67% in Europe, 78% in Asia or Africa, 80% in the Middle East, and 85% in South America.



Gonzalo Mariani, MD, Hospital Italiano de Buenos Aires

The short and long-term benefits of the use of human milk for preterm infants are well known (1,2). However, there are barriers to provide human milk for every preterm infant. To improve our use of human milk in these fragile infants, it is important to have a multidisciplinary team comprised of physicians, nurses, lactation consultants, and mothers that reviews the literature, educates the team members, and is aware of the mother’s needs and unit’s resources.

First, we must address gaps in knowledge. Many parents and providers are not fully informed of the immense benefits of human milk and the importance of timing and dose. Early initiation of human milk use is related to more effective and longer duration of breastfeeding (4,5). Higher volumes of human milk consumed are associated with improved neurodevelopmental outcomes (6). Obstetricians, neonatologists, nurses, residents, and fellows should collaborate with lactation consultants to give a uniform message and to actively work on maternal support and promotion of lactation.

Encouragement of human milk feeding for preterm infants is safe, effective, and an ethical responsibility for health care professionals (6-8). Team leaders must ensure that adequate resources are provided. The lower rate of use of human milk in high income countries suggests that financial resources by themselves are not enough. While cultural issues are important factors, it is essential to have excellent teamwork with a commitment to use human milk as a critical component in preterm infants’ care.

Explore Further

Hear more from Dr. Gonzalo Mariani by viewing the presentation from the 2017 Annual Quality Congress, “Improving Neonatal Care Around the World: Experience Argentina,” on VON’s Learning Management System.


  1. Underwood MA. Human milk for the premature infant. Pediatr Clin North Am. 2013;60(1):189-207.
  2. American Academy of Pediatrics Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 2012;129(3):e827-841.
  3. American College of Obstetricians and Gynecologists Committee on Health Care for Underserved Women. ACOG Committee Opinion No. 361: Breastfeeding: maternal and infant aspects. Obstet Gynecol. 2007;109(2 Pt 1):479-480
  4. Meier PP, Johnson TJ, Patel Al, Rossman B. Evidence-based methods that promote human milk feeding of preterm infants. An expert review. Clin Perinatol 2017; 44:1-22.
  5. Meier PP, Engstrom JL, Patel AL et al. Improving the use of human milk during and after the NICU stay. Clin Perinatol. 2010; 37:217–245.
  6. Vohr BR, Poindexter BB, Dusick AM et al. Persistent beneficial effects of breast milk ingested in the neonatal intensive care unit on outcomes of extremely low birth weight infants at 30 months of age. Pediatrics 2007; 120:e953-e959.
  7. Sisk PM, Lovelady CA, Dillard RG, Gruber KJ. Lactation counseling for mothers of very low birth weight infants: Effect on maternal anxiety and infant intake of human milk. Pediatrics 2006; 117:e67–e75.
  8. Miracle DJ, Fredland V. Provider encouragement of breastfeeding: Efficacy and ethics. J Midwifery Womens Health 2007;52:545–548.

Your VON Data in Action

This report is made possible by Vermont Oxford Network members who voluntarily contribute data in a global effort to improve the care of high-risk newborns. VON members can view center-specific data by logging on to Nightingale and benchmark against this NICU by the Numbers report.

Editors: Erika Edwards, PhD, MPH; Roger Soll, MD

Analyst: Lucy Greenberg, MS