Neonatology has always been a bargain--even when we weren't very good at it!

Objective: We wondered whether Neonatal Intensive Care Unit resources for Extremely Low Birth Weight infants have always been disproportionately devoted to survivors, even when ELBW infants were very likely to die.

Methods: We documented survival and length of stay (LOS) for 2354 ELBW infants (BW 450-1000 g) admitted to the NICU at the University of Chicago between 1978 and 2003. NICU bed-days were a proxy for medical expenses.

Results: Over the past 25 years, ELBW admissions have risen four-fold from 25 to 100/year, and ELBW bed-days have risen ten-fold, from 700 to 7000/year. In 1978, when ELBW mortality was 80%, only 30% of ELBW bed-days were expended on non-survivors. Currently, the percentage of ELBW non-survivor bed days (NSBD) is below 10%. Even more striking, as soon as there were any survivors with BW 450-750 g, the NSBD index fell below 30%, and settled quickly around 10%.

Conclusions: It is almost self-evident that there are no credible distributive justice arguments to deflect NICU care for ELBW infants now, when survival is so good. But, surprisingly, even when NICU survival was much worse, there have never been credible distributive justice arguments against NICU care for infants with BW <1000 g, whether dollars spent on survivors or 'intact survivors' is the outcome measure.