Policy Forum
Oct 2008

The Cost of Saving the Tiniest Lives: NICUs versus Prevention

Jonathan Muraskas, MD and Kayhan Parsi, JD, PhD
Virtual Mentor. 2008;10(10):655-658. doi: 10.1001/virtualmentor.2008.10.10.pfor1-0810.




Lantos writes eloquently about how NICUs have emerged over the last several decades as major revenue generators in the world of inpatient pediatric care. Like transplantation, neonatal medicine captures the public's imagination as few other areas of medicine do—patients who would have surely died years ago are now miraculously saved. NICUs and transplantation are also valence issues for the public: everyone supports saving premature children and extending people's lives. The questions that Lantos poses for policymakers and health care leaders are, "Why do we have such an epidemic of prematurity in the United States?" and "Why don't we do a better job of addressing this public health problem?"



Initiating NICU Care

Lantos has stated that he does not believe reimbursement influences treatment decisions in the NICU [1]. In our estimation, the following factors have more often trumped cost considerations in the decision to initiate NICU care: (1) Fear of litigation and a 30 percent cesarean section rate. Despite popular belief, no significant differences exist in the outcomes of premature infants delivered by vaginal versus the surgical method. Yet, the medical-legal focus often rests on the final 2 hours of a 7,000-hour pregnancy so the pressure to practice defensive medicine is strong. (2) A substantial rise in the use of assisted reproductive techniques, which triggers a heightened "rescue" mentality because parents have incurred physical and financial burdens in seeking to conceive and deliver a baby. (3) Legislation such as the Baby Doe law. The Baby Doe legislation in the early 1980s, prompted by the case of a newborn with Down syndrome and a nonlethal condition treatable by surgery, stated that newborns should receive proper medical care unless therapy was deemed futile [3, 4].

Lifelong Cost

NICU costs are just the beginning. The extraordinary cost of managing the medical, educational, and social needs of extremely low-birth-weight newborns, as well as term newborns with perinatal asphyxia, often are not discussed with parents early in the infant's care. Advances in neonatal medicine in the last 20 years give an infant born 13 weeks early and weighing 2 pounds a 90 percent chance of survival. But, short- and long-term outcomes have not improved significantly in the last 2 decades. The incidence of cerebral palsy remains essentially unchanged. Approximately 25 percent of all newborns younger than 26 weeks' gestation have a handicap severe enough to prohibit them from functioning independently [5, 6].


Most U.S. clinicians practice a "wait until death appears certain" strategy in the management of newborns [8]. A strategy of withholding treatment on grounds of a statistically grim prognosis can be implemented for a short period of time. An extremely premature newborn or an asphyxiated, term newborn has a "clinical honeymoon" period that usually ends by the third day of life. The incidence of infection, respiratory deterioration, bleeding in the brain, and seizures can surface at this time. An experienced clinician, using evidence-based medicine and ethics, could redirect a family's focus to the future of its newborn if the clinical scenario suggests considering withdrawal or withholding of intensive care medicine [9].

Alternate Means for Saving Babies




  1. Pope TM. Involuntary passive euthanasia in U.S. courts: reassessing the judicial treatment of medical futility cases. Marquette Elder's Advisor. 2008;9(2)248.

  2. Catlin A.  Extremely long hospitalizations of newborns in the United States: data, descriptions, dilemmas. J Perinatol. 2006;26(12):742-748.
  3. Adams MM, Barfield WD. The future of very preterm infants: learning from the past. JAMA. 2008;299(12):1477-1478.
  4. Ballard DW, Li Y, Evans J, Ballard RA, Ubel PA. Fear of litigation may increase resuscitation of infants born near the limits of viability. J Pediatr. 2002;140(6):713-718.
  5. Marlow N, Wolke D, Bracewell MA, Samara M, EPICure Study Group. Neurologic and developmental disability at six years of age after extremely preterm birth. N Engl J Med. 2005;352(1):9-19.
  6. Swamy GK, Ostby T, Skjaerven R. Association of preterm birth with long-term survival, reproduction, and next-generation preterm birth. JAMA. 2008;299(12):1429-1436.
  8. Rhoden NK. Treating Baby Doe: the ethics of uncertainty. Hastings Cent Rep. 1986;16(4):34-42.
  9. Tyson JE, Stoll BJ. Evidence-based ethics and the care and outcome of extremely premature infants. Clin Perinatol. 2003;30(2):363-387.
  10. Behrman RE, Butler AS, Editors, Committee on Understanding Preterm Birth and Assuring Healthy Outcomes. Board on Health Sciences Policy. Preterm Birth—Causes, Consequences, and Prevention. Washington, D.C. : National Academies Press; 2007.

  11. Wen SW, Smith G, Yang Q, Walker M. Epidemiology of preterm birth and neonatal outcome. Semin in Fetal and Neonatal Med. 2004;9(6):429-435.


Virtual Mentor. 2008;10(10):655-658.


