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Continuing our thread on autopsy from May, this issue carries papers that examine the alternatives to autopsy where consent for a full post mortem examination is not forthcoming. In their review, Wright and Lee point out that there are a number of ways in which babies may yield further important information as to why they died, and whether there was anything else the matter with them before death. But none of these approaches compares favourably with a full autopsy, and as Lyon comments, full autopsy has to remain the gold standard. Lyon goes on to remind us that we should not be coy in approaching parents for consent to autopsy. Not approaching parents deprives them of their right to have an informed discussion about the possibility of autopsy, and failing to offer the opportunity could be seen as paternalism masquerading as kindness.
See pages F284 and F285
KICKING THE HABIT
How best to get babies off of their mothers’ opiates? About 18 months ago, Jackson et al (Arch Dis Child Fetal Neonatal Ed 2003;88:F2–5) emphasised the absence of decent head to head trials of different drugs to treat neonatal abstinence syndrome. Now we have a good trial from Glasgow that directly assists us in choosing the best treatment for these babies: morphine is better than phenobarbitone. What astonished me, but may surprise others less, was that 17% of neonatal unit admissions at the Princess Royal Maternity Hospital were related to neonatal abstinence syndrome.
See page F300
“TO HEAR IS TO FORGET”
Parents may completely forget the process by which they allowed their baby to participate in a neonatal clinical trial. Given that there is so much that parents forget about their baby’s time in a NICU, perhaps this finding is not all that surprising. Nevertheless, Stenson et al do the research community a service by quantifying the extent of this forgetting, and this information complements the strand about assent for participation in trials that runs through recent issues of F&N. On the surface their data seem to suggest that the process of consent needs to be improved, but what it may really indicate is that routinely giving parents a copy of their consent form, and offering them a further opportunity to talk about the trial before they leave the unit, would be a good idea.
See page F321
ENTERAL FOOD FOR THOUGHT
Flidel-Rimon et al provide observational evidence of benefit for early minimal enteral feeding by looking at the effects on nosocomial infection and showing that there is a protective advantage, and no apparent increased risk of necrotising enterocolitis. In contrast, Van Elburg et al in a small randomised controlled trial of growth restricted infants found no adverse effect of early minimal enteral feeding, but noted that to date the meta-analysis jury is out on its possible net benefits: some more large trials are still needed. From yet another angle, Gounaris et al present data showing that the theophyllines can interfere with gastric emptying. Inch by painful inch, we learn a little more about how to feed our tiny patients safely.
See pages F289, F293, and F297
Most clinical myths probably start from either an interesting clinical occurrence, or a good idea in the bath. They gain an aura of respectability by being written down as a speculation by someone authoritative, then get quoted in a textbook and acquire the status of a “fact”. For instance, we all know, or thought we knew, that preterm meconium staining of the amniotic fluid heralds a high risk for listeriosis. However, when Tybulewicz et al did their careful case control study, listeria did not even feature. What did emerge is that meconium can indeed have a sinister connotation, but the association is with cerebral haemorrhages, suggesting that unpleasant things other than listeriosis have been happening to these babies either before or during preterm labour. We also “know” that four limb blood pressure measurements are useful for diagnosing aortic coarctation in babies; but actually, they aren’t (Crossland et al).
See pages F325 and F328