Unwarranted NICU admissions rise among normal birth weight infants

This paper raises the question of whether an inordinate number of larger infants are being unnecessarily exposed to costly and invasive intensive care. However, as the authors acknowledge, other potential contributing factors need to be considered. For example, the authors recognized that birth certificates used for data collection do not always include vital health information on the mother. Rates of maternal obesity (higher rates of diabetes, pre-eclampsia and antenatal infections) and associated neonatal complications (higher rates of mortality, congenital abnormalities and lower Apgar scores) have increased significantly over this time period, even though their statistical modeling using only birth weight failed to confirm this theory. In addition, admissions for neonatal abstinence syndrome (NAS) due to the opioid epidemic increased fourfold during this same time period which could partially explain the increased number of admissions seen in larger term infants; this suggests that rapid changes in social and demographic factors can result in more infants requiring neonatal intensive care.

Furthermore, the study was limited to 22 states in 2007 and 39 in 2012 and does not include data for admission to level 2 nurseries. It is possible that many of the term infants could have been appropriately cared for in lower level Special Care Nurseries, but were admitted to a NICU because of geographical proximity, payer preference, referral patterns/networks, liability concerns or maternal preferences. However, these lower-level nurseries could easily and appropriately be utilized for term babies with milder symptoms as long as qualified medical and nursing personnel are available to care for them. It would be helpful to have more information in this area so alternative models could be considered where only the highest risk mothers and critically ill newborns are transferred to a level 3 or 4 institution, while lower-risk mothers and infants are cared for in less intensive and costly community settings.

Overall, this is a useful study for assessing the trends in neonatal admission rates nationwide. Further research might stratify admission by diagnoses for each birth weight and gestational age category. The existing data indicating increased survival rates for neonates suggest that the expense of neonatal care is balanced by the inherent risks, although such risks could be better defined in future studies.

Meredith Dixon, MD
Department of Pediatrics
The Floating Hospital for Children
Tufts Medical Center

Jonathan M. Davis, MD
Department of Pediatrics
The Floating Hospital for Children
Tufts Medical Center

From 2007 to 2012 in 38 U.S. states and District of Columbia, the authors found a significant increase in newborn admissions to neonatal ICUs, raising the possibility of overuse of NICU care with attendant increase in hospital costs. Importantly, newborns were likely to be full term and of normal birth weight. This trend is concerning, but not surprising and the exact causes which likely are multifactorial should be explored.

As more hospitals have expanded delivery and NICU services, there is pressure to admit newborns to NICUs to justify their existence. Moreover, the practice of delivery hospitals to care for newborns only in ‘rooming-in’ settings has resulted in the lack of newborn nurseries that can observe and care for infants who are mildly ill or require only antibiotic therapy. Unfortunately, the decrease in the time that residents spend in NICUs may only further worsen this trend.

Pablo J Sánchez, MD
Infectious Diseases in Children Editorial board member
Nationwide Children’s Hospital
The Ohio State University

Mohannad Moallem, MD
Department Of Neonatology
Nationwide Children’s Hospital
The Ohio State University