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Resource distribution in neonatology: beyond the Pareto principle
  1. John A F Zupancic1,2,
  2. Dmitry Dukhovny3
  1. 1Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
  2. 2Division of Newborn Medicine, Harvard Medical School, Boston, Massachusetts, USA
  3. 3Department of Pediatrics, Oregon Health & Science University, Portland, Oregon, USA
  1. Correspondence to Dr John A F Zupancic, Department of Neonatology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Rose Building Room 318, Boston, MA 02215, USA; jzupanci{at}

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The field of neonatology grew up with an abiding philosophy of rescue. The first two decades of our published literature are replete with evaluations of technology to provide cardiorespiratory support to the most vulnerable of infants, and our community is rightly proud of its accomplishments in lowering the threshold of viability while making some gains in rates of associated morbidities. However, the enormous effect sizes seen in that era—for therapies such as surfactant, inhaled nitric oxide for term respiratory failure or antenatal corticosteroids—are now much less frequently demonstrated. That presents us with an opportunity to identify additional, new priorities.

Late in the 19th century, economist Vilfredo Pareto identified the concept that wealth is distributed according to a power law, in which most resources are concentrated among a small number of individuals. In neonatology, the same principle has applied to our research priorities: the large majority of effort, federal funding, advocacy and publication have been targeted to the sickest, smallest infants. In the USA, 1.9% of the 2013 annual birth cohort was delivered before 32 weeks, while 9.5% was delivered between 32 and 36 weeks.1 In contrast, a PubMed search yields 540 citations with reference to moderate and late prematurity in their titles when compared with 6068 referring to the extremely or very-preterm population.i Thus, it might be argued that 17% of premature infants have commanded 92% of our scholarly attention.

For many years, this state of affairs was supportable by our belief that these high-volume infants did not contribute markedly to the aggregate burden of …

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