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Neonatology is a subspecialty of
pediatrics Paediatrics (American and British English differences, also spelled pediatrics or pædiatrics) is the branch of medicine that involves the medical care of infants, children, and Adolescence, adolescents. The American Academy of Pediatrics recom ...

pediatrics
that consists of the medical care of newborn infants, especially the ill or premature newborn. It is a
hospital A hospital is a health care institution providing patient treatment with specialized Medical Science, health science and Allied Healthcare, auxiliary healthcare staff and medical equipment. The best-known type of hospital is the general hospit ...

hospital
-based specialty, and is usually practised in
neonatal intensive care unit A neonatal intensive care unit (NICU), also known as an intensive care nursery (ICN), is an intensive care unit image:Intensivstation (01) 2007-03-03.jpg, 220px, Intensive care unit An intensive care unit (ICU), also known as an intensive thera ...
s (NICUs). The principal patients of
neonatologist Neonatology is a subspecialty of pediatrics Paediatrics (American and British English differences, also spelled pediatrics or pædiatrics) is the branch of medicine that involves the medical care of infants, children, and Adolescence, ado ...
s are
newborn An infant (from the Latin word ''infans'', meaning 'unable to speak' or 'speechless') is the more formal or specialised synonym for the common term ''baby'', meaning the of . The term may also be used to refer to of other organisms. A n ...

newborn
infants who are ill or require special medical care due to prematurity,
low birth weight Low birth weight (LBW) is defined by the World Health Organization The World Health Organization (WHO) is a specialized agency of the United Nations United Nations Specialized Agencies are autonomous organizations working with the United N ...
,
intrauterine growth restriction Intrauterine growth restriction (IUGR) refers to poor growth of a fetus while in the mother's womb during pregnancy. The causes can be many, but most often involve poor maternal nutrition or lack of adequate oxygen supply to the fetus. At least ...
,
congenital malformation A birth defect, also known as a congenital disorder, is a condition present at birth Birth is the act or process of bearing or bringing forth offspring, also referred to in technical contexts as parturition. In mammals, the process is initiate ...
s (
birth defect A birth defect, also known as a congenital disorder, is a condition present at birth Birth is the act or process of bearing or bringing forth offspring, also referred to in technical contexts as parturition. In mammals, the process is initiat ...
s),
sepsis Sepsis is a life-threatening condition that arises when the body's response to infection An infection is the invasion of an organism's body by , their multiplication, and the reaction of tissues to the infectious agents and the s they pr ...
,
pulmonary hypoplasia Pulmonary hypoplasia is incomplete development of the lung The lungs are the primary organs of the respiratory system in human Humans (''Homo sapiens'') are the most populous and widespread species of primates, characterized by bipeda ...
or
birth asphyxia Birth is the act or process of bearing or bringing forth offspring In biology, offspring are the young born of living organism, organisms, produced either by a single organism or, in the case of sexual reproduction, two organisms. Collective o ...
.


Historical developments

Though high infant mortality rates were recognized by the medical community at least as early as the 1860s, advances in modern neonatal intensive care have lead to a significant decline in infant mortality in the modern era. This has been achieved through a combination of technological advances, enhanced understanding of newborn physiology, improved sanitation practices, and development of specialized units for neonatal intensive care. Around the mid-19th century, the care of newborns was in its infancy and was lead mainly by obstetricians; however, the early 1900s, pediatricians began to assume a more direct role in caring for neonates. The term neonatology was coined by Dr. Alexander Schaffer in 1960. The American Board of Pediatrics established an official sub-board certification for neonatology in 1975. In 1835, the Russian physician Georg von Ruehl developed a rudimentary incubator made from two nestled metal tubs enclosing a layer of warm water. By the mid-1850s, these "warming tubs" were in regular use at the Moscow Foundling Hospital for the support of premature infants. 1857, Jean-Louis-Paul Denuce was the first to publish a description of his own similar incubator design, and was the first physician to describe its utility in the support of premature infants in medical literature. By 1931, Dr. A Robert Bauer added more sophisticated upgrades to the incubator which allowed for humidity control and oxygen delivery in addition to heating capabilities, further contributing to improved survival in newborns. The 1950s brought a rapid escalation in neonatal services with the advent of
mechanical ventilation Mechanical ventilation, assisted ventilation or intermittent mandatory ventilationIntermittent Mandatory Ventilation (IMV) refers to any mode of mechanical ventilation where a regular series of breaths are scheduled but the ventilator senses p ...
of the newborn, allowing for survival at an increasingly smaller birth weight. In 1952, the anesthesiologist Dr.
Virginia Apgar Virginia Apgar (June 7, 1909August 7, 1974) was an American physician A physician (American English), medical practitioner (English in the Commonwealth of Nations, Commonwealth English), medical doctor, or simply doctor, is a professional wh ...

Virginia Apgar
developed the
Apgar score The Apgar score is a method to quickly summarize the health of newborn 222x222px, Eight-month-old sororal twin sisters An infant (from the Latin word ''infans'', meaning 'unable to speak' or 'speechless') is the more formal or specialise ...

Apgar score
, used for standardized assessment of infants immediately upon delivery, to guide further steps in resuscitation if necessary. The first dedicated
neonatal intensive care unit A neonatal intensive care unit (NICU), also known as an intensive care nursery (ICN), is an intensive care unit image:Intensivstation (01) 2007-03-03.jpg, 220px, Intensive care unit An intensive care unit (ICU), also known as an intensive thera ...
(NICU) was established at Yale-Newhaven Hospital in Connecticut in 1965. Prior to the development of the NICU, premature and critically ill infants were attended to in nurseries without specialized resuscitation equipment. In 1968, Dr. Jerold Lucey demonstrated that hyperbilirubinemia of prematurity (a form of
neonatal jaundice Neonatal jaundice is a yellowish discoloration of the white part of the eyes and skin Skin is the layer of usually soft, flexible outer tissue covering the body of a vertebrate animal, with three main functions: protection, regulation, and se ...

neonatal jaundice
) could be successfully treated through exposure to artificial blue light. This led to widespread use of phototherapy, which has now become a mainstay of treatment of neonatal jaundice. In the 1980s, the development of pulmonary surfactant replacement therapy further improved survival of extremely premature infants and decreased chronic lung disease, one of the complications of mechanical ventilation, among less severely premature infants.


Academic training

In the
United States The United States of America (U.S.A. or USA), commonly known as the United States (U.S. or US) or America, is a country Continental United States, primarily located in North America. It consists of 50 U.S. state, states, a Washington, D.C., ...

United States
, a ''neonatologist'' is a physician ( MD or DO) practicing neonatology. To become a
neonatologist Neonatology is a subspecialty of pediatrics Paediatrics (American and British English differences, also spelled pediatrics or pædiatrics) is the branch of medicine that involves the medical care of infants, children, and Adolescence, ado ...
, the physician initially receives training as a
pediatrician Paediatrics ( also spelled pediatrics or pædiatrics) is the branch of medicine Medicine is the science Science () is a systematic enterprise that builds and organizes knowledge Knowledge is a familiarity, awareness, or understan ...
, then completes an additional training called a fellowship (for 3 years in the US) in neonatology. In the United States of America most, but not all neonatologists, are
board certified Board certification is the process by which a physician A physician (American English), medical practitioner (English in the Commonwealth of Nations, Commonwealth English), medical doctor, or simply doctor, is a professional who practices medi ...
in the specialty of Pediatrics by the
American Board of Pediatrics The American Board of Pediatrics (ABP) was founded in 1933. It is one of the 24 certifying boards of the American Board of Medical Specialties Established in 1933, the American Board of Medical Specialties (ABMS) is a non-profit A nonprof ...
or the
American Osteopathic Board of Pediatrics The American Osteopathic Board of Pediatrics (AOBP) is an organization that provides board certification to qualified Doctor of Osteopathic Medicine, Doctors of Osteopathic Medicine (D.O.) who specialize in the diagnosis and treatment of medical dis ...
and in the sub-specialty of Neonatal-Perinatal Medicine also by the American Board of Pediatrics or American Osteopathic Board of Pediatrics. Most countries now run similar programs for post-graduate training in Neonatology, as a subspecialisation of pediatrics. In the
United Kingdom The United Kingdom of Great Britain and Northern Ireland, commonly known as the United Kingdom (UK) or Britain,Usage is mixed. The Guardian' and Telegraph' use Britain as a synonym for the United Kingdom. Some prefer to use Britain as shorth ...

United Kingdom
, after graduation from
medical school A medical school is a tertiary education Tertiary education, also referred to as third-level, third-stage or post-secondary education, is the education Education is the process of facilitating learning, or the acquisition of knowled ...
and completing the two-year
foundation programme The UK Foundation Programme is a two-year structured programme of workplace-based learning for junior doctors that forms a bridge between medical school and specialty training. The programme aims to provide a safe, well-supervised environment for ...
, a physician wishing to become a neonatologist would enroll in an eight-year paediatric specialty training programme. The last two to three years of this would be devoted to training in neonatology as a subspecialty. Neonatal Nurse Practitioners (NNPs) are advanced practice nurses that specialize in neonatal care. They are considered providers and often share the workload of NICU care with resident physicians. They are able to treat, plan, prescribe, diagnose and perform procedures within their scope of practice, defined by governing law and the hospital where they work. Neonatal nursing is subspecialty of nursing that specialize in neonatal care.


Spectrum of care

Rather than focusing on a particular organ system, neonatologists focus on the care of newborns who require hospitalization in the
Neonatal Intensive Care Unit A neonatal intensive care unit (NICU), also known as an intensive care nursery (ICN), is an intensive care unit image:Intensivstation (01) 2007-03-03.jpg, 220px, Intensive care unit An intensive care unit (ICU), also known as an intensive thera ...
(NICU). They may also act as general pediatricians, providing well newborn evaluation and care in the hospital where they are based. Some neonatologists, particularly those in academic settings who perform clinical and basic science research, may follow infants for months or even years after hospital discharge to better assess the long-term outcomes. The infant is undergoing many adaptations to extrauterine life, and its physiological systems, such as the
immune system The immune system is a network of biological processes that protects an organism from diseases. It detects and responds to a wide variety of pathogens, from viruses to parasitic worms, as well as Tumor immunology, cancer cells and objects such ...
, are far from fully developed. Diseases of concern during the neonatal period include: * Anemia of prematurity *
Apnea of prematurity Apnea ( BrE: apnoea) is the cessation of breathing. During apnea, there is no movement of the muscles of inhalation, and the volume of the lungs initially remains unchanged. Depending on how blocked the airways are ( patency), there may or m ...
*
Atrial septal defect Atrial septal defect (ASD) is a congenital heart defect A congenital heart defect (CHD), also known as a congenital heart anomaly and congenital heart disease, is a defect in the structure of the heart The heart is a cardiac muscle, mu ...

Atrial septal defect
*
Atrioventricular septal defect Atrioventricular septal defect (AVSD) or atrioventricular canal defect (AVCD), also known as "common atrioventricular canal" (CAVC) or " endocardial cushion defect" (ECD), is characterized by a deficiency of the atrioventricular septum of the hear ...
*
Benign neonatal hemangiomatosis Benign neonatal hemangiomatosis is a rare List of cutaneous conditions, skin condition that presents in infancy with multiple benign tumors called infantile hemangiomas, but without hemangiomas in other organs. See also * Infantile hemangioma * ...
*
Brachial plexus injury A brachial plexus injury (BPI), also known as brachial plexus lesion, is an injury to the brachial plexus The brachial plexus is a network () of nerves (formed by the anterior rami of the lower four Spinal nerve#Cervical nerves, cervical nerves and ...
*
Bronchopulmonary dysplasia Bronchopulmonary dysplasia (BPD; formerly chronic lung disease of infancy) is a chronic lung disease in which premature infants, usually those who were treated with supplemental oxygen, require long-term oxygen. The alveoli that are present tend to ...
*
Cerebral palsy Cerebral palsy (CP) is a group of movement disorders Movement disorder refers to any clinical syndrome with either an excess of movement or a paucity of voluntary and involuntary movements, unrelated to weakness or spasticity Spasticity () is ...

Cerebral palsy
*
CHARGE syndrome CHARGE syndrome (formerly known as CHARGE association) is a rare syndrome A syndrome is a set of medical signs and symptoms Signs and symptoms are the observed or detectable signs, and experienced symptoms of an illness, injury, or condition ...
*
Cleft palate A cleft lip contains an opening in the upper lip Lips are a visible body part at the mouth of many animals, including humans. Lips are soft, movable, and serve as the opening for food intake and in the articulation of sound and speech. Hu ...
*
Coarctation of the aorta Coarctation of the aorta (CoA or CoAo), also called aortic narrowing, is a congenital condition whereby the aorta The aorta ( ) is the main and largest artery An artery (plural arteries) () is a blood vessel that takes blood away from th ...
*
Congenital adrenal hyperplasia Congenital adrenal hyperplasia (CAH) is a group of Genetic disorder#Autosomal recessive, autosomal recessive disorders characterized by impaired cortisol synthesis. It results from the deficiency of one of the five enzymes required for the Biosynthe ...

Congenital adrenal hyperplasia
*
Congenital diaphragmatic hernia Congenital diaphragmatic hernia (CDH) is a birth defect A birth defect, also known as a congenital disorder, is a condition present at childbirth, birth regardless of its cause. Birth defects may result in disability, disabilities that may be phy ...
*
Congenital heart disease A congenital heart defect (CHD), also known as a congenital heart anomaly and congenital heart disease, is a defect in the structure of the heart The heart is a cardiac muscle, muscular Organ (biology), organ in most animals, which pumps b ...
*
Diffuse neonatal hemangiomatosis Diffuse neonatal hemangiomatosis is a potentially fatal disorder where multiple benign blood vessel tumors (hemangiomas) are present in the skin and other organs. The most common site of internal organ involvement is the liver. Death can result from ...
*
DiGeorge syndrome DiGeorge syndrome, also known as 22q11.2 deletion syndrome, is a syndrome caused by a microdeletion on the long arm of . While the symptoms can vary, they often include , specific facial features, frequent infections, , and . Associated conditio ...
*
Encephalocele Encephalocele is a neural tube defect characterized by sac-like protrusions of the brain A brain is an organ (anatomy), organ that serves as the center of the nervous system in all vertebrate and most invertebrate animals. It is located in the ...
*
Gastroschisis Gastroschisis is a birth defect in which the baby's intestines extend outside of the abdomen through a hole next to the belly button. The size of the hole is variable, and other organs including the stomach and liver may also occur outside the bab ...
*
Hemolytic disease of the newborn Hemolytic disease of the newborn, also known as hemolytic disease of the fetus and newborn, HDN, HDFN, or erythroblastosis foetalis, is an alloimmune condition that develops in a fetus A fetus American and British English spelling difference ...
*
Hirschsprung disease Hirschsprung's disease (HD or HSCR) is a birth defect A birth defect, also known as a congenital disorder, is a condition present at birth Birth is the act or process of bearing or bringing forth offspring, also referred to in technical con ...
*
Hypoplastic left heart syndrome #REDIRECT Hypoplastic left heart syndrome Hypoplastic left heart syndrome (HLHS) is a rare congenital heart defect in which the left side of the heart is severely underdeveloped. It may affect the left ventricle A ventricle is one of two large cha ...

Hypoplastic left heart syndrome
*
Hypoxic ischemic encephalopathy Cerebral hypoxia is a form of Hypoxia (medical), hypoxia (reduced supply of oxygen), specifically involving the human brain, brain; when the brain is completely deprived of oxygen, it is called ''cerebral anoxia''. There are four categories of c ...
*
Inborn errors of metabolismInborn errors of metabolism form a large class of genetic diseases involving congenital disorders of enzyme activities. The majority are due to defects of single genes that code for enzymes that facilitate conversion of various substances (substrate ...

Inborn errors of metabolism
*
Intraventricular hemorrhage Intraventricular hemorrhage (IVH), also known as intraventricular bleeding, is a bleeding into the brain's ventricular system, where the cerebrospinal fluid is produced and circulates through towards the subarachnoid space. It can result from ...
*
Lissencephaly Lissencephaly (, meaning "smooth brain") is a set of rare brain disorders where the whole or parts of the surface of the brain appear smooth. It is caused by Neuronal migration disorder, defective neuronal migration during the 12th to 24th weeks ...

Lissencephaly
*
Meconium aspiration syndrome Meconium aspiration syndrome (MAS) also known as neonatal aspiration of meconium is a medical condition affecting newborn infants. It describes the spectrum of disorders and pathophysiology of newborns born in meconium-stained amniotic fluid (MSAF) ...
*
Necrotizing enterocolitis Necrotizing enterocolitis (NEC) is a devastating intestinal disease that affects premature infants. Symptoms may include poor feeding, bloating, decreased activity, blood in the stool, vomiting of bile, bowel death, multiorgan failure and even dea ...
*
Neonatal abstinence syndrome Neonatal withdrawal or neonatal abstinence syndrome (NAS) is a withdrawal syndrome of infant 222x222px, Eight-month-old sororal twin sisters An infant (from the Latin word ''infans'', meaning 'unable to speak' or 'speechless') is the mor ...
* Neonatal cancer *
Neonatal jaundice Neonatal jaundice is a yellowish discoloration of the white part of the eyes and skin Skin is the layer of usually soft, flexible outer tissue covering the body of a vertebrate animal, with three main functions: protection, regulation, and se ...

Neonatal jaundice
* Neonatal respiratory distress syndrome * Neonatal lupus erythematosus * Neonatal conjunctivitis * *
Neonatal tetanus Neonatal tetanus is a form of generalised tetanus that occurs in newborns. Infants who have not acquired passive immunity from the mother having been immunised are at risk. It usually occurs through infection of the unhealed umbilical stump, parti ...
* Neonatal sepsis * Neonatal bowel obstruction * Neonatal stroke * Neonatal diabetes mellitus *
Neonatal alloimmune thrombocytopenia Neonatal alloimmune thrombocytopenia (NAITP, NAIT, NATP or NAT) is a disease A disease is a particular abnormal condition that negatively affects the structure A structure is an arrangement and organization of interrelated elements in a ...
*
Neonatal herpes simplex Neonatal herpes simplex is a rare but serious condition, usually caused by vertical transmissionVertical transmission of symbionts Symbiosis (from Greek , , "living together", from , , "together", and , bíōsis, "living") is any type of a cl ...
* Neonatal hemochromatosis * Neonatal meningitis *
Neonatal hepatitis Neonatal hepatitis refers to many forms of liver The liver is an organ only found in vertebrates which detoxifies various metabolites, synthesizes proteins and produces biochemicals necessary for digestion and growth. In humans, it is locat ...
*
Neonatal hypoglycemia Neonatal hypoglycemia occurs when the neonate's blood glucose level is less than the newborn's body requirements for factors such as cellular energy and metabolism. There is inconsistency internationally for diagnostic thresholds. In the US, hypogl ...
*
Neonatal cholestasisNeonatal cholestasis defines persisting conjugated hyperbilirubinemia in the newborn with conjugated bilirubin levels exceeding 15% (5.0 mg/dL) of total bilirubin level. The disease is either due to defects in bile excretion from hepatocytes or ...
*
Neonatal seizure A neonatal seizure is a seizure A seizure, formally known as an epileptic seizure, is a period of symptoms due to abnormally excessive or synchronous neuronal activity in the brain A brain is an organ (anatomy), organ that serves as the ce ...
*
Omphalocele Omphalocele or omphalocoele also called exomphalos, is a rare abdominal wall defect. Beginning at the 6th week of development, rapid elongation of the gut and increased liver size reduces intra abdominal space, which pushes intestinal loops out of ...
*
Patent ductus arteriosus ''Patent ductus arteriosus'' (PDA) is a medical condition in which the ''ductus arteriosus The ductus arteriosus, also called the ductus Botalli, named after the Italian physiologist Leonardo Botallo, is a blood vessel in the developing fetus c ...

Patent ductus arteriosus
*
Perinatal asphyxia Perinatal asphyxia (also known as neonatal asphyxia or birth asphyxia) is the medical condition resulting from deprivation of oxygen to a newborn infant that lasts long enough during the birth process to cause physical harm, usually to the brain. I ...
*
Periventricular leukomalacia Periventricular leukomalacia (PVL) is a form of white-matter brain injury, characterized by the necrosis (more often coagulation) of white matter near the lateral ventricles.Vlasyuk V.V. Periventricular leukomalacia in children. SPb, "Гелик ...
* Persistent pulmonary hypertension of the newborn *
Persistent truncus arteriosus Persistent truncus arteriosus (PTA), often referred to simply as Truncus Arteriosus, is a rare form of congenital heart disease A congenital heart defect (CHD), also known as a congenital heart anomaly and congenital heart disease, is a defect i ...
*
Pulmonary hypoplasia Pulmonary hypoplasia is incomplete development of the lung The lungs are the primary organs of the respiratory system in human Humans (''Homo sapiens'') are the most populous and widespread species of primates, characterized by bipeda ...
*
Retinopathy of prematurity Retinopathy of prematurity (ROP), also called retrolental fibroplasia (RLF) and Terry syndrome, is a disease of the eye Eyes are organs of the visual system. They provide living organisms with vision, the ability to receive and process v ...
*
Spina bifida Spina bifida (Latin for "split spine"; SB) is a in which there is incomplete closing of the and the around the during . There are three main types: spina bifida occulta, meningocele and myelomeningocele. Meningocele and myelomeningocele may ...
*
Spinal muscular atrophy Spinal muscular atrophy (SMA) is a rare neuromuscular disorder that results in the loss of motor neurons and progressive muscle wasting. It is usually diagnosed in infancy or early childhood and if left untreated it is the most common genetic ...
*
Supraventricular tachycardia Supraventricular tachycardia (SVT) is an umbrella term for arising from the . This is in contrast to the other group of fast heart rhythms - , which start within the . There are four main types of SVT: , , (PSVT) and . The symptoms of SVT incl ...
*
Tetralogy of Fallot Tetralogy of Fallot (TOF), formerly known as Steno-Fallot tetralogy, is a congenital heart defect A congenital heart defect (CHD), also known as a congenital heart anomaly and congenital heart disease, is a defect in the structure of the hear ...

Tetralogy of Fallot
*Total (or partial) anomalous pulmonary venous connection *
Tracheoesophageal fistula #REDIRECT Tracheoesophageal fistula A tracheoesophageal fistula (TEF, or TOF; see spelling differences Despite the various English dialects spoken from country to country and within different regions of the same country, there are only slig ...
* Transient tachypnea of the newborn *
Transposition of the great vessels Transposition of the great vessels (TGV) is a group of congenital heart defects involving an abnormal spatial arrangement of any of the great vessels: superior and/or inferior venae cavae, pulmonary artery A pulmonary artery is an artery ...
*
Tricuspid atresia Tricuspid atresia is a form of congenital heart disease A congenital heart defect (CHD), also known as a congenital heart anomaly and congenital heart disease, is a defect in the structure of the heart or great vessels that is present at birth ...

Tricuspid atresia
*
Trisomy A trisomy is a type of polysomy in which there are three instances of a particular chromosome A chromosome is a long DNA Deoxyribonucleic acid (; DNA) is a molecule File:Pentacene on Ni(111) STM.jpg, A scanning tunneling mic ...
13/18/21 * VACTERL/VATER association *
Ventricular septal defect A ventricular septal defect (VSD) is a defect in the ventricular septum The interventricular septum (IVS, or ventricular septum, or during development septum inferius) is the stout wall separating the ventricles, the lower chambers of the hear ...

Ventricular septal defect
*
Vertically transmitted infection A vertically transmitted infection is an infection An infection is the invasion of an organism's body tissues by disease-causing agents, their multiplication, and the reaction of host A host is a person responsible for guests at an eve ...
s


Compensation

Neonatologists earn significantly more than general pediatricians. In 2018, a typical pediatrician salary in the United States ranged from $221,000 to $264,000, whereas the average salary for a neonatologist was about $299,000 to $355,000.


Hospital costs

Premature birth Preterm birth, also known as premature birth, is the birth Birth is the act or process of bearing or bringing forth offspring, also referred to in technical contexts as parturition. In mammals, the process is initiated by hormones which cause ...

Premature birth
is one of the most common reasons for hospitalization. The average hospital costs from 2003 to 2011 for the maternal and neonatal surgical services were the lowest hospital costs in the U.S. In 2012, maternal or neonatal hospital stays constituted the largest proportion of hospitalizations among infants, adults aged 18–44, and those covered by Medicaid. Between 2000 and 2012, the number of neonatal stays (births) in the United States fluctuated around 4.0 million stays, reaching a high of 4.3 million in 2006. Maternal and neonatal stays constituted 27 percent of hospital stays in the United States in 2012. However, the mean hospital costs remained the lowest of the three types of hospital stay (medical, surgical, or maternal and neonatal). The mean hospital cost for a maternal/neonatal stay was $4,300 in 2012 (as opposed to $8,500 for medical stays and $21,200 for surgical stays in 2012).


References

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