The Initial Maternal Cost of Providing 100mL
of Human Milk for Very Low Birth Weight Infants
in the Neonatal Intensive Care Unit
Briana J. Jegier,1,2Paula Meier,1,3Janet L. Engstrom,1and Timothy McBride2
Objectives: Human milk (HM) feeding is associated with lower incidence and severity of costly prematurity-
specific morbidities compared to formula feeding in very low birth weight (VLBW; <1,500g) infants. However,
the costs of providing HM are not routinely reimbursed by payers and can be a significant barrier for mothers.
This study determined the initial maternal cost of providing 100mL of HM for VLBW infants during the early
neonatal intensive care unit (NICU) stay.
Methods: This secondary analysis examined data from 111 mothers who provided HM for their VLBW infants
during the early NICU stay. These data were collected during a multisite, randomized clinical trial where milk
output and time spent pumping were recorded for every pumping session (n¼13,273). The cost analysis
examined the cost of the breast pump rental, pump kit, and maternal opportunity cost (an estimate of the cost of
Results: Mean daily milk output and time spent pumping were 558.2 mL (SD¼320.7; range¼0–2,024) and 98.7
minutes (SD¼38.6; range¼0–295), respectively. The mean cost of providing 100mL of HM varied from $2.60 to
$6.18 when maternal opportunity cost was included and from $0.95 to $1.55 when it was excluded. The cost per
100mL of HM declined with every additional day of pumping and was most sensitive to the costs of the breast
pump rental and pump kit.
Conclusions: These findings indicate that HM is reasonably inexpensive to provide and that the maternal cost of
providing milk is mitigated by increasing milk output over the early NICU stay.
terocolitis) in a dose–response manner during the early post-
birth period for very low birth weight (VLBW; <1,500g)
infants.1–18Thus, access to adequate amounts of HM from
the infant’s own mother should be a priority in the neonatal
intensive care unit (NICU). However, the basic lactation
equipment that these mothers need—a hospital-grade electric
breast pump and a pump collection kit19,20—is not routinely
reimbursed by public and private third-party payers.21Thus,
these mothers must incur the cost for the breast pump and
pump kit, an economic burden that translates into a barri-
er20,22to providing HM for a VLBW infant. In the immediate
post-birth period, a mother who cannot access a breast pump
and kit has two choices: (1) attempt to initiate lactation with
less costly, but significantly less effective, manual or electric
uman milk (HM) feedings reduce the risk of costly and
handicapping morbidities (e.g., sepsis, necrotizing en-
pumps, thereby risking lactation complications (e.g., mastitis,
lactation failure); or (2) feed donor milk and=or commercial
formula. The purpose of this study was to examine the initial
during the early post-birth period and to compare this cost to
the alternatives: donor milk and commercial formula.
Materials and Methods
This study is a secondary analysis of an existing dataset of
132 mothers who provided HM for their VLBW infants im-
mediately after birth between January 2002 and March 2004.
These data were originally collected as part of a multisite,
randomized clinical trial that tested the efficiency, efficacy,
a new hospital-grade electric breast pump (Symphony Pump;
Medela, Inc., McHenry, IL).23,24
Departments of1Women, Children and Family Nursing and3Pediatrics, Rush University Medical Center, Chicago, Illinois.
2School of Public Health, Saint Louis University, St. Louis, Missouri.
Volume 5, Number 2, 2010
ª Mary Ann Liebert, Inc.
The sampleforthisstudy wasdrawnfrom therecordsofthe
132 mothers who participated in the randomized clinical trial.
Inclusion criteriaforthe original study wereas follows:birthof
an infant(s) with birth weight <1,250g and=or gestational age
?32 weeks; infant admitted to NICU; mother provided HM;
and written informed consent for study participation. For this
secondaryanalysis,records formothersenrolledinthe original
study were eligible for analysis if completed milk output logs
were returned.23,24Of the 132 original records, 116 met this
criterion and were eligible for inclusion in this analysis. Five
records were excluded because no pumping times were
documented, leaving a total study sample size of 111 records.
The median number of days for study participation was 21
(range¼5–41; interquartile range¼17–24). This analysis was
limitedtothe first31daysoftheoriginalstudy because only10
mothers provided data beyond 31 days. The demographic
characteristics of the sample are displayed in Table 1. The
original study was approved by the Institutional Review
Boards at all four sites where data were collected, and the
secondary analysis was approved by the Institutional Review
Boards at Rush University Medical Center (Chicago, IL) and
Saint Louis University (St. Louis, MO).
Daily maternal milk output.
milk output log to record total milk output to the nearest
Mothers used a standardized
10mL from each breast for each pumping session throughout
the study. Total milk output for each pumping session was
calculated by adding the milk output for the right and left
breasts. Total daily milk output was calculated by adding
the total milk output from each pumping session for each
Daily maternal time spent pumping.
milk output log to record the start and end time for each
pumping session for each breast throughout the original
study. Total time for each pumping session was calculated by
subtracting the start time from the end time for each breast. If
the mother pumped both breasts simultaneously for an equal
amount of time, the total time was equal to the time for one
breast. If the mother pumped longer on one breast, the total
time was equal to the longer pumping time. If the mother did
not pump both breasts simultaneously, the total time was
calculated by adding the pumping times for both breasts.
Total daily time was calculated by adding the total time from
each pumping session for each study day.
Mothers used the
HM provision costs.
was calculated using the cost for the minimum items that are
universally required by all mothers of VLBW infants. These
items included: the monthly breast pump rental fee (BPRF);
the breast pump collection kit cost (BPCK); and the maternal
opportunity cost (MOC). The cost of the containers to store
HM is borne bythe hospital to ensure that the containers meet
hospital standards for food safety and infection control. The
definitions for the universally required costs are below. All
costs are presented in 2008 U.S. dollars.
The monthly BPRF was measured as the charge from the
institution to the mother for rental of the hospital-grade
electric breast pump (BPRF¼$35). BPRF is typically offered
on a monthly basis.21
The BPCK was measured as the institutional charge to the
mother (BPCK¼$57). This cost is a one-time fixed cost be-
cause kits do not become obsolete, ineffectual, or damaged in
the first month of pumping.25
The MOC measures the monetary value of the mother’s
time spent pumping and is traditionally defined as the ma-
ternal wage that the mother forgoes by choosing to do
something other than paid work. MOC was calculated by
multiplying the maternalhourlywagebythe totaldailyhours
spent pumping. Maternal hourly wage was estimated using
the imputation model of Winkler et al.26The imputation
model predicts wage using a regression equation where the
independent predictor variables are maternal characteristics,
including age, age squared, education, race, ethnicity, and
The maternal cost of providing HM
The procedures for the original study were detailed in
previous publications23,24and are briefly summarized here.
Mothers were enrolled in the study within 48 hours of giving
birth and were instructed to simultaneously pump both
breasts six to eight times per day for a minimum of 15–20
minutes per session until the onset of lactogenesis II. Lacto-
genesis II is the point in time when the mother’s milk ‘‘comes
in.’’ After this time, mothers were instructed to continue
pumping six or eight times per day and to pump until the
Table 1. Characteristics of the Mothers
and Their Infants
VariableMean?SD or n (%)
Highest level of education (n¼111)
Less than high school
High school graduate
Total family income (n¼109)
Less than $5,000
$50,000 or more
Prefer not to answer=doesn’t know
WIC eligible (n¼111)a
Maternal age in years (n¼111)
Infant birth weight (g) (n¼123)b
Infant gestational age (weeks) (n¼111)
aWIC, Women, Infants and Children.
bInfant birth weight is the average birth weight of all infants born
to study mothers; 146 infants were born to 111 mothers. Complete
birth weight data were available for 123 infants.
72JEGIER ET AL.
steady flow of milk had stopped for 2 minutes. Demographic
data were collected using a questionnaire. Time spent
pumping and milk output were collected using a standard-
ized milk output log for 3 weeks following study enrollment
or until the mother met either of the following conditions: (1)
mother discontinued pumping or (2) mother completed all
study questionnaires and interviews.
Complete time and milk output data were available for
99.2% of the 13,273 pumping sessions. The procedures for
missing data were as follows: If time spent pumping was
recorded but not milk output, output was estimated using the
mean of the following two estimates: the average milk output
during that pumping session on the day before and the day
after the missing pumping session and the average milk
output for each session that study day; If milk output was
recorded but not time spent pumping, time was estimated
using the mean of the following two estimates: the average of
the time spent pumping during that pumping session on the
daybefore andthe dayafterthe missingpumpingsession and
the average of the time spent pumping for each session that
Data were managed using SPSS for Windows Version 14
(SPSS, Inc., Chicago, IL) and Microsoft (Redmond, WA) Excel
2003. Frequencies and descriptive statistics were used to de-
scribe the data. Descriptive statistics were calculated for each
day of the study period and for the entire study period.
The cost of providing 100mL of HM was calculated using
the costingtechniques outlined byDrummondetal.27Inbrief,
these techniques consist of four steps: (1) define analysis as-
sumptions; (2) identify and measure factors that influence
cost; (3) conduct a sensitivity analysis; and (4) evaluate and
compare the financial value of the next alternatives: Donor
milk and commercial formula. All costs are presented in 2008
The sources of cost for this study were the BPRF, the BPCK,
and the MOC. Both the BPRF and BPCK were considered
fixed costs because the mother pays the BPRF and BPCK cost
regardless of whether or not she pumps for the whole month.
MOC was a variable cost because the time pumped varied for
each day throughout the study period. The total cost of
providing HM was measured as: cost per 100mL¼([BPRFþ
BPCKþMOC]=total milk output)?100.
After the cost per 100mL was calculated using the above
equation, a one-way sensitivity analysis was conducted to
determine which of the three components of the cost estimate
(BPRF, BPCK, or MOC) most influenced the total cost of
providing HM. Sensitivity analyses are performed by repla-
cing the original cost estimates with alternative estimates
obtained from market prices such as those listed by various
suppliers and retailers. Published market prices from sup-
pliers and retailers were used in this sensitivity analysis to be
conservative in calculating the variation in the cost of pro-
viding HM. This conservative approach was used because
published market prices are typically higher than an institu-
tion’s negotiated price. Additionally, published market prices
represent a more accurate determination of the maternal
provision cost if she must incur these costs herself.
The sensitivity for the BPRF and BPCK was investigated
using average market prices (?2 SD). The mean BPRF and
BPCK from the market review were $69.92 (SD¼$10.45) and
$50.08 (SD¼$4.57), respectively.
The sensitivity of the cost estimate to MOC was examined
using a planned wage variation. The variation was the 2008
federal minimum wage ($6.55)28; this value is the minimum
monetary value for legal employment in the United States
regardless of state and local government mandates.
Finally, the cost of HM per 100mL was compared to the
next best alternatives (donor milk and commercial formula).
Donor milk is purchased by the hospital to ensure that the
milk meets hospital standards for food safety and infection
control. The mean cost per 100mL for donor milk was ob-
tained by contacting several institutions that purchase donor
milk and milk banks that sell donor milk (D.L. Spatz, N.M.
Hurst, and D.J. Miracle, personal communications). The mean
cost per 100mL of donor milk was $13.59 per 100mL
The mean cost per 100mL for commercial formula was
obtained using a three-step procedure. First, budgetary re-
ports documenting the unit price paid by the hospital for
formula products for VLBW infants at one of the study in-
stitutions were examined (M. Fogleman, Rush University
formulas were classified into three categories: powdered
preterm formula (Enfacare Lipil 22?[Mead Johnson, Evans-
ville, IN], Neosure?[Abbott Nutrition, Columbus, OH]),
powdered specialty formula (Nutramigen?[Mead Johnson],
Portagen?[Mead Johnson], Pregestimil?[Mead Johnson],
Elecare?[Abbott Nutrition], Neocate?[Nutricia North
America, Rockville, MD]), and liquid ready-to-feed preterm
formula (Specialcare?[Abbott Nutrition] ready-to-feed).
NICU dietitian for each powdered formula using the two
most common caloric dilutions: 20–22 Cal=oz and 24–27
Cal=oz (M. Fogleman, Rush University Medical Center in-
stitutional formulary for mixing formula, 2009). The cost per
100 fluid mL for each dilution was calculated by converting
the cost per fluid ounce to the cost per milliliter multiplied by
100mL. Lastly, a cost estimate for 100mL of sterile water to
mix the formula was added to each powdered formula esti-
mate to obtain the final cost per 100mL of powdered formula
(Rush University Medical Center, purchasing department
cost per 100mL of formula by category and caloric dilution.
The cost per 100mL ranged from $0.63 for regular 20–22
Cal=oz powdered preterm formula to $2.97 per 100mL for
liquid ready-to-feed 20–22 Cal preterm formula.
The mean daily milk output and time spent pumping were
558.2 mL (SD¼320.7; range¼0–2,024) and 98.7 minutes
(SD¼38.6; range¼0–295), respectively. These measures
varied throughout the study period (Fig. 1). Mean daily milk
output increased steadily during the first 8 study days and
then remained relatively constant through study day 24.
Mean daily time spent pumping increased sharply during the
first 4 study days and then trended downward through study
day 26. Greater variability in milk output and time spent
pumping during the last week of this study was probably due
COST OF PROVIDING 100ML OF HUMAN MILK IN THE NICU 73
to the declining sample size (75% of the sample had com-
pleted the original study by day 24).
The mean cost of providing 100mL of HM was calculated
with and without MOC (Table 3). When MOC was included,
$6.18. When MOC was excluded, the mean cost of providing
100mL of HM varied from $0.95 to $1.55.
Figure 2 is a cost curve that depicts the average cost of
providing 100mL of HM for each day throughout the study
of pumping. The curve is stable through day 24 of the study
and becomes less stable thereafter, which was probably related
to the declining sample size during the last week of the study.
The sensitivity analysis (Table 3) demonstrates that the cost
per 100mL of HM is sensitive to all three of the cost compo-
nents: BPRF, BPCK, and MOC. MOC was the largest con-
tributor to total cost per 100mL of HM, with its addition
tripling the cost per 100mL. However, variation in maternal
wage had less effect on total cost compared to variation in the
cost of the BPRF and BPCK. For example, increasing wage
from the federal minimum wage to the imputed wage, a
96.2% increase, resulted in only a 92.3% increase in the cost
per 100mL. In contrast, the cost per 100mL changed pro-
portionately with variations in the cost of the BPRF and
BPCK. Changing the cost of the BPRF and BPCK from the
actual hospital charges to the higher limit mean market cost, a
63.2% increase, resulted in a 63.1% increase in the cost per
than the cost per 100mL of donor milk ($13.59) regardless of
the variations in the cost of the BPRF, BPCK, and MOC. The
cost per 100mL of HM including MOC was less expensive
than liquid ready-to-feed preterm formula ($2.97) when MOC
was valued at the federal minimum wage ($2.60). In contrast,
the cost per 100mL of HM including MOC was more expen-
sive than all formulas for all higher variations in MOC. The
Table 2. The Average Cost of Preterm Formula by Formula Category
and Caloric Dilution (2008 U.S. Dollars)
Average cost for
100mL of formula
Cost for 100mL
Liquid ready-to-feed preterm formula
NA, not applicable.
aPreterm formula includes Enfacare Lipil 22 and Neosure.
bSpecialty formula includes Nutramigen, Portagen, Pregestimil, Elecare, and Neocate.
13579 11 1315 1719 2123 2527 29 31
Mean daily output of human milk (mL)
Mean daily time spent pumping (min)
Mean daily output of human milk
Mean daily time spent pumping
The mean daily milk output (in mL) and the mean daily time spent pumping (in minutes) for study participants
74JEGIER ET AL.
cost per 100mL of HM excluding MOC ($0.95–$1.55) was less
expensive than the 24–27 Cal=oz specialty formula ($1.06)
and the liquid ready-to-feed preterm formula ($2.97). The cost
per 100mL of HM, excluding MOC, was more expensive than
the 20–22 Cal=oz and 24–27 Cal=oz preterm formula and the
20–22 Cal=oz specialty formula.
This is the first study to estimate the initial maternal cost of
providing 100mL of HM for VLBW infants and included only
the required components that all mothers need to provide
their HM: The BPRF, the BPCK, and the maternal time. The
findings from this study suggest that institutions and payers
may actually realize a cost savings by reimbursing costs for
the BPRF and the BPCK. Our data reveal that the cost of HM
from the infant’s own mother ($0.95–$1.55) is less expensive
than donor milk ($13.59), specialty formula ($1.06), and
ready-to-feed formula ($2.97) that are commonly used in the
NICU for this population.
This analysis also demonstrated that the cost per 100mL of
HM declined with each additional day of pumping (Fig. 2).
This cost reduction is a predictable outcome because maternal
milk output increases significantly during the early post-birth
period29without an increase in pumping time or fixed costs.
The increasing daily milk output rapidly mitigates the initial
costs of providing milk, with a low mean cost per 100mL of
$1.03 on study day 22. Although not examined in this study,
the cost per 100mL in the second month post-birth would
likely be lower because the fixed cost of the BPCK is removed
and milk output should remain stable or increase.29Remov-
ing the cost of the BPCK in month 1 supports this speculation
because the mean cost per 100mL of HM decreases to $0.36
(Table 3). These findings suggest a return on investment for
the BPRF and BPCK cost during the first weeks of pumping.
Moreover, this trend suggests that the return on investment
Table 3. Mean Maternal Cost of Providing 100mL of HM (n¼111) Calculated
Using Actual Hospital Charges and Estimated Market Prices (2008 U.S. Dollars)
Actual hospital chargesMean market price
and kit ($50.08)
and kit ($40.94)
and kit ($59.22)
Calculated without MOC
Calculated with MOC using
Federal minimum wage ($6.55)
Imputed wage (mean¼$13.44)
13579 1113 15 17 1921232527 2931
Mean cost per 100 mL
Actual hospital charges
Lower limit mean market price
Mean market price estimate
Upper limit mean market price
estimated market price (2008 U.S. dollars).
The average daily cost of 100mL of HM for pumping supply costs (BPRF and BPCK): actual hospital charges and
COST OF PROVIDING 100ML OF HUMAN MILK IN THE NICU 75
would remain stable or potentially increase with additional
months of pumping. This trend also suggests that HM from
the infants’ own mother is less expensive than donor milkand
commercial formula over the entire NICU stay.
These findings have important implications for clinical
practice and health policy. To initiate lactation for a VLBW
infant, mothers must pay between $90 and $150 for the first
month’s BPRF and the purchase of the BPCK. Most payers
and institutions do not reimburse or pay these costs, so they
are borne by the mothers.20–24This initial cost can be pro-
hibitive because preterm birth means other unexpected ex-
penses (e.g., increased insurance co-payments, hospital
parking fees, lost wages). Programs that provide the BPRF
and BPCK to mothers have reported high rates of HM feed-
ings, even among low-income families.19,20,22These successes
dispel the myth that mothers do not initiate lactation because
they are disinterested or unmotivated.20,22Rather, the success
when the cost barriers associated with lactation for a VLBW
infant are removed or reduced.
In this analysis, MOC was the largest overall contributor to
the cost of providing 100mL of HM, and removing this cost
substantially reduced the cost per 100mL (Table 3). This
finding raises the fundamental question of how MOC should
be treated in economic analyses of breastfeeding or providing
HM. From an economic perspective, opportunity cost is a
standard measure in cost analyses because it captures the
value of a person’s time when she or he chooses one activity,
such as pumping, over other activities, such as paid work or
In economic analyses of breastfeeding or providing HM, it
can be argued that MOC should be excluded from cost ana-
lyses because most mothers are not medically eligible to re-
turn to paid work during the first weeks post-birth. However,
other experts contend that including the value of maternal
time allows society to examine the economic contribution that
mothers make when they choose to breastfeed or provide
HM.30Because both arguments are legitimate, we have cho-
sen to report the cost of providing 100mL of HM with and
without MOC, an approach that seems pragmatic for subse-
quent economic studies of breastfeeding and providing HM.
Finally, this study examines the initial maternal cost of
providing HM and only analyzed the costs for items that are
universally required by all mothers of VLBW infants to initi-
ate HM feeding, including the BPRF, the BPCK, and maternal
time. This study is a necessary first step in determining the
cost of HM feedings because if a mother does not initiate
other maternal and institutional costs,19,20are not relevant.
Future analyses should examine additional potential sources
of maternal cost (e.g., breastfeeding bras, pads, creams, pil-
lows, additional dietary needs, prescription pharmaceuticals)
and institutional costs (e.g., HM storage containers, lactation
specialist care, hospital freezer space) that are associated with
In conclusion, the findings from this study estimate that the
initial maternal cost of providing her milk for her VLBW in-
fant is less than $1.00 per 100mL and that her milk costs less
than donor milk and many types of commercial formula used
in the NICU. Although the cost of providing HM is relatively
small, it remains an economic barrier for many mothers.
Removal of this economic barrier is the first step toward
ensuring that access to effective lactation equipment becomes
a standard of patient care for all mothers of VLBW infants.
Providers, payers, and Women, Infants and Children (WIC)
clinics can use these findings to justify the cost of providing
BPRF and BPCK for mothers of VLBW infants.
This article was funded by grants AHRQ 1 R36 HS016012
and NIH 1 R01 NR010009. The original clinical trial that
provided the dataset for this analysis was funded by Medela,
for their contribution to this manuscript: Mary Fogleman,
M.S., NICU dietitian at Rush University Medical Center;
and Mother’s Own Milk Bank, Texas Children’s Hospital and
Assistant Professor of Pediatrics, Baylor College of Medicine;
Donna J. Miracle, Ph.D., Director of Research and Clinical
Operations, Indiana Mothers’ Milk Bank, Inc.; and Diane L.
Spatz, Ph.D., Helen M. Shearer Term Associate Professor of
Nutrition and Associate Professor of Healthcare of Women
at the Children’s Hospital of Philadelphia.
B.J.J. has received research funding from Medela, Inc. P.M.
has received research funding from Medela, Inc. and Prolacta
and Abbott Nutritionals, and has provided consultation to
special projects for Medela, Inc. J.L.E. has received research
funding from Medela, Inc. T.M. has no conflict of interest to
declare for this article.
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Address correspondence to:
Briana J. Jegier, Ph.D.
Department of Women, Children and Family Nursing
Rush University Medical Center
600 South Paulina, Suite 1080
Chicago, IL 60612
COST OF PROVIDING 100ML OF HUMAN MILK IN THE NICU77