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Fantoms
  1. Martin Ward Platt, Associate editor

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HEALTHY BABIES

This issue leads with four papers on healthy babies, term and preterm. In the first of these, the use of pulse oximetry is evaluated as an adjunct to the neonatal examination. But why measure oxygen saturation in otherwise healthy term babies? Richmond et al make a persuasive case. In their hands, oximetry provided early warning of subclinical hypoxaemia, with its implications for congenital heart disease and other neonatal diseases, in a small number of apparently normal, healthy babies. It appeared to be acceptable to parents, 99.9% of whom consented to participation in the study, and they achieved an impressive 98% coverage of inborn babies. Like the authors, readers will be disappointed that the sensitivity for picking up babies who turned out to have aortic coarctation was only three out of six; but given the wide confidence intervals of this observation, it will be important to know how oximetry fares among a larger number of babies with coarctation. This is exciting preliminary work, which is continuing on a larger scale, and I hope others will be stimulated to evaluate pulse oximetry in their own populations of healthy newborns. See p 83

MAKING CONNECTIONS

Sudden intrauterine unexplained death, or SIUD; it is tempting to wonder whether there could be any connection with sudden infant death syndrome. After all, the CESDI data showed that some individual characteristics, available antenatally, of women whose babies subsequently suffer a cot death, can predict 40% of the deaths in just 8% of the population. So, do women whose babies die unexpectedly and withoutexplanation in utero share any of these characteristics? Very few population based data sets exist in which this possibility could be explored, but Frøen et al have used the Norwegian registry to attempt this for the population of Oslo and its neighbouring county. The verdict: no shared maternal determinants or fetal characteristics, at least not in terms of routinely collected data, and not in this population. But it’s a question that might be worth asking in other populations, perhaps with a broader socioeconomic spread than Norway. See p 118

DOUBLE JEOPARDY

We used to think that we had cracked the problem of phenylketonuria once we had a good screening programme, efficient dietary management, and good data on the relationship between blood phenylalanine levels and long term outcome. We always knew that the grown up girls would have to set their metabolic house in order again when they contemplated pregnancy, and that failure to do so would have nasty effects on the fetus. But the rates of suboptimal control and the associated poor outcomes presented by Magee et al from Northern Ireland make disturbing reading, and their plea for reinstating national registration of PKU seems compelling given that the problem of affected mothers will only increase over the next few years. See p 141

MIND

Our “mind” paper is a case control study of adverse behavioural or psychiatric outcomes among low birth weight babies. Such problems in children who were of low birth weight have been reported by others, but Elgen et al have attempted to refine our understanding of their nature, showing a preponderance of attention problems, with no relation to IQ. They have also tried to separate out confounding factors such as maternal and family characteristics; whether they have fully succeeded in doing this will be for readers to judge. See p 128

. . . AND BRAIN

Continuing a dualist approach, our brain paper is a national study of cerebral palsy in twins. The hypothesis that the early death of a monochorionic co-twin may be responsible for a substantial proportion of children who later turn out to have “idiopathic” cerebral palsy is gaining an increasing evidence base. This paper from Pharoah et al lends the hypothesis further circumstantial support. The other paper by Parker et al describes a mechanism by which neonatal cerebral infarction can take place as a result of paradoxical embolism because of the special conditions of the transitional circulation. There will be an unknown number of cases of cerebral palsy arising by this mechanism, which is directly analogous to that proposed for the “dying twin” hypothesis. See p 122 and 125

WHAT ARE THE CHANCES, DOC?

I don’t think that any of us are very happy about the kind of conversation that all too often occurs at no notice with a distressed family and a mother in established labour at 20 something weeks of gestation. We make the best of an inauspicious situation and try to inform, comfort, empower, and support the parents. All too often we fall short. Zupancic et al are therefore to be congratulated on their brave attempt to inject some objective understanding of this difficult consultation into our collective consciousness. Particularly salutary is the fact that the doctors commonly misidentified those parents wishing to make their own decisions. Other researchers wishing to explore and improve this consultation may want to consider different ways of analysing it—for instance, video or audio recordings—which rely less on factual recall. In the meantime, we will continue to meet with distressed families whose first question to us is still “what are the chances, doc?” See p 113

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