A symbolic image representing neonatal care in NICU and PICU settings.

Neonatal Care: Why Where a Baby Dies Matters

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Samir D’Costa in Health & Wellness October 2026 • 4 min read.

"A new study reveals critical differences in end-of-life decisions between neonatal and pediatric ICUs, impacting how and why newborns die."


When a newborn's life hangs in the balance, every decision matters. For parents and medical teams, deciding on the best course of action in neonatal intensive care units (NICUs) and pediatric intensive care units (PICUs) is fraught with complexity. While both units provide critical care, a recent study sheds light on significant differences in how end-of-life decisions are approached, ultimately affecting the outcomes for these tiny patients.

Previous research has largely focused on preterm infants, identifying prematurity, congenital malformations, perinatal asphyxia, and sepsis as major causes of neonatal mortality. However, a gap exists in understanding the nuances between NICUs and PICUs in managing full-term infants. Factors such as birth weight, gestational age, and underlying illnesses play a role, but the influence of the care setting itself remained unclear—until now.

This article delves into a groundbreaking study comparing neonatal deaths and end-of-life decisions in NICUs and PICUs within the same children's hospital. By examining the causes of death, the timing of decisions, and the overall approach to care, we uncover the critical factors that influence these heart-wrenching choices and what they mean for the future of neonatal care.

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The Neonatal Period

The neonatal period covers the first four weeks of an infant’s life. During this time, sleeping and feeding schedules are established, and bonding begins. The American Academy of Pediatrics represents 3,200 neonatologists and promotes multidisciplinary, family-centered neonatal care to improve the care and survival of vulnerable newborns.

NICU vs. PICU: Unveiling Key Differences in Neonatal End-of-Life Decisions

A symbolic image representing neonatal care in NICU and PICU settings.

The study, conducted at a Dutch university hospital, retrospectively analyzed data from 235 full-term infants who died within 28 days of life between 2003 and 2013. Researchers meticulously examined patient data from both the NICU (n=199) and PICU (n=36), looking at factors such as length of stay, causes of death, and the nature of end-of-life decisions.

One of the most striking findings was the difference in the primary reasons for admission and the ultimate causes of death between the two units:

  • NICU: Admissions were mainly due to asphyxia (52.8%) and congenital malformations (42.2%).
  • PICU: Congenital malformations predominated (97.2%), with cardiac problems being the primary concern (83.3%, p<0.001).
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What Autopsies Reveal

A 2022 review reports that the cause of death is known for most neonates who die while admitted to a neonatal intensive care unit. In many high-income countries, death follows a redirection of care. The review also states that neonatal autopsies can reveal previously undetected diseases or malformations, providing information relevant to improving neonatal care.

Study Limitations

A retrospective study examined 235 full-term infants who died within 28 days of life between 2003 and 2013. The infants included 199 deaths in the neonatal intensive care unit and 36 in the paediatric intensive care unit at the same children’s hospital. The study authors noted that their research had limitations, which should be considered when interpreting comparisons between the two units.

These differences profoundly influenced the median age of death. In the NICU, it was three days, while in the PICU, it was eight days (p<0.001). Despite intensive care, mortality rates also varied significantly, with 4.0% in the NICU and a substantially higher 25.0% in the PICU. Further analysis revealed disparities in how treatment was discontinued or redirected:

Improving Compassionate Care: The Path Forward

This study underscores the critical need for tailored approaches to end-of-life care in NICUs and PICUs. The differing patient populations, underlying disorders, and even the attitudes of the medical teams all contribute to the variations observed. Recognizing these differences is the first step toward optimizing care and ensuring the most compassionate outcomes for newborns and their families.

Further research is essential to explore the ethical considerations and decision-making processes in greater depth. Understanding the factors that influence these choices—and how they align with the best interests of the child and the wishes of the family—will pave the way for more consistent and supportive care.

By fostering open communication, providing comprehensive support, and embracing a holistic approach to neonatal care, we can strive to make these difficult decisions with greater clarity, empathy, and a steadfast commitment to the well-being of every child.

What the records and comparisons leave uncertain

  • The authors could not rule out that differences in clinicians’ education or ethics shaped their end-of-life approaches.[1]
  • The study did not establish whether differences between neonatologists and pediatric intensivists affected decision-making.[1]

A retrospective comparison of full-term infant deaths in the NICU and PICU

PopulationFull-term infants who died within 28 days of life[2]
Sample size235[2]
SettingA Dutch tertiary children's hospital, in its NICU and PICU[2]
Duration2003 to 2013[2]
ComparisonNICU versus PICU[2]
Main outcomeDifferences in neonatal deaths and end-of-life decisions between the NICU and PICU[2]
Effect sizeMedian age of death was three days in the NICU and eight days in the PICU[2]
p-valuep < 0.001[2]
FundingNo external funding[2]
Conflicts of interestNo conflicts of interest declared[2]
Times cited14[2]

How this hospital comparison has been cited and contrasted

A later review highlighted the contrast in deaths despite full intensive care, noting that the NICU comparison excluded extremely preterm infants; this places the finding specifically in the context of non-preterm NICU deaths.[3]

That review also described the NICU and PICU decision rationales as differing, emphasizing predicted poor quality of life as the stated basis more often in the NICU than in the PICU.[3]

Questions the documented comparisons leave open

  • How much of the difference in decisions reflects the infants’ conditions, and how much reflects clinicians’ approaches?[1]
  • How consistently do these unit-specific patterns appear in other hospitals and patient groups?[2]

Sources

  1. Deaths and end-of-life decisions differed between neonatal and paediatric intensive care units at the same children's hospital (Europe PMC, 2018)
  2. Deaths and end‐of‐life decisions differed between neonatal and paediatric intensive care units at the same children's hospital (Wiley, 2017)
  3. End of life care in the setting of extreme prematurity – practical challenges and ethical controversies (Seminars in Fetal and Neonatal Medicine, 2023)

About this Article -

Written with AI assistance from published research, and reviewed by the Mystum team. See our About page for more information.

This article is based on research published under:

DOI-LINK: 10.1111/apa.14061, Alternate LINK

Title: Deaths And End-Of-Life Decisions Differed Between Neonatal And Paediatric Intensive Care Units At The Same Children'S Hospital

Subject: General Medicine

Journal: Acta Paediatrica

Publisher: Wiley

Authors: Maartje C. Snoep, Nicolaas J.G. Jansen, Floris Groenendaal

Published: 2017-09-25

Everything You Need To Know

1

What are the main differences between a neonatal intensive care unit (NICU) and a pediatric intensive care unit (PICU)?

The neonatal intensive care unit (NICU) and the pediatric intensive care unit (PICU) are both specialized units within hospitals, providing intensive care for critically ill infants and children. However, they cater to different patient populations and health challenges. The NICU focuses on newborns, especially those born prematurely or with health complications, while the PICU cares for older infants, children, and sometimes adolescents with a wider range of medical conditions.

2

How does the care setting impact end-of-life decisions and outcomes?

The location of care profoundly impacts the approach to end-of-life decisions. In the NICU, admissions often stem from asphyxia and congenital malformations, leading to a median age of death at three days. In contrast, the PICU sees a predominance of congenital malformations, particularly cardiac issues, with a median age of death at eight days. These differences in underlying conditions and the setting of care influence not only the timing of end-of-life decisions but also the overall mortality rates, highlighting the need for tailored approaches to care.

3

What are the primary causes of death in the NICU versus the PICU?

The main causes of death differ significantly between the NICU and PICU. In the NICU, asphyxia (52.8%) and congenital malformations (42.2%) are primary drivers, while in the PICU, congenital malformations (97.2%), especially cardiac problems (83.3%), are predominant. These varying causes underscore the importance of understanding the unique challenges faced by each unit and tailoring care strategies accordingly.

4

What factors are considered when making end-of-life decisions in these units?

End-of-life decisions involve complex considerations, including the patient's prognosis, quality of life, and the family's wishes. The study highlights that in the NICU, the approach may differ compared to the PICU. In the NICU, where deaths often occur sooner, the focus may be on interventions to address immediate life-threatening conditions. In the PICU, with patients often facing chronic conditions, the decision-making process may involve a more extended period of evaluation and consideration of long-term outcomes, including discontinuing or redirecting treatments.

5

Why is it important to understand these differences in neonatal care?

Understanding the differences in end-of-life decisions and patient outcomes between the NICU and PICU is crucial for improving care. The study emphasizes that recognizing these disparities is the first step towards optimizing care. This involves tailoring approaches, considering patient populations, underlying disorders, and the attitudes of medical teams. The aim is to ensure compassionate outcomes for newborns and their families, acknowledging the complexities involved in these critical decisions.

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