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Chasing an ASTEC
The ASTECS trial, first planned almost 20 years ago, opened in 1995. It is still of interest now because of the lingering concern that the improvement in short term outcomes from the administration of antenatal betamethasone to mothers undergoing elective caesarean section at term might be counterbalanced by adverse effects that might only become manifest in the long term. Such effects might plausibly include more (or less) atopic disease, or altered cognitive function. So Stutchfield et al are to be congratulated on their tenacious follow up of the subjects of the original trial to evaluate rates of asthma and atopic disease, and measures of behavioural and educational function, in subjects now aged between 8 and 15 years. The results are reassuring: there is a good case for using antenatal betamethasone for term elective caesarean section, without concerns about long term harm. See page F195
A.R.T. and preterm outcome
It is well known that artificial reproductive technologies (ART) are associated with both preterm delivery and a two-fold increase in the prevalence of congenital malformations. But for a given degree of prematurity, might developmental outcome among babies conceived artificially be worse in comparison with natural conceptions? Abdel-Latif et al try to answer this important question using a large birth cohort from New South Wales and the Australian Capital Territory; they conclude that amongst the most preterm (below 27 weeks) the use of artificial conception appears to be associated with increased disability, but not death. However a substantial proportion of both cases and controls were lost to follow up, rates of loss were different between cases and controls, and smoking habits were not recorded, so their finding needs to be replicated in other birth cohorts before we can be completely confident about it. See page F212
The science of predicting outcome
Those who are already convinced that it is possible to develop ‘accurate’ predictors of death or neurodevelopmental outcome among preterm babies will enjoy the paper by Boland et al. Confining themselves to babies born at less than 26 weeks’ gestation, they showed that babies born in Victoria in 2005 achieved better outcomes than would be predicted by the National Institute of Child Health and Human Development calculator: from 114 cases, only 6 out of 10 babies in Victoria actually died, or survived with significant disability, compared with 7 out of 10 predicted by the NICHD calculator. How much this refinement really helps when dealing with parents faced with extremely preterm delivery I leave to the reader. My own view is that the true value of these approaches lies in refining case-mix adjustment when comparing outcomes of different neonatal facilities. See page F201
Laying on of hands
Therapeutic touch as a mode of healing is as old, if not older, than the practice of medicine itself. So would it be useful to help protect tiny babies from the physiological effects of painful procedures? Honda et al suggest that it might. But rather than studying infants subjected to painful procedures, they created a standardised condition for study using sensory punctate stimuli; they found that therapeutic touch reduced the degree of brain activation as measured using near-infrared spectroscopy. So the next question is whether the laying on of hands would be effective in a truly painful situation. See page F244
A real pea-souper
The resemblance of meconium, as modified by its suspension in amniotic fluid, to pea soup, has long been both an apt description and a source of tasteless humour. Real pea soup therefore lent itself as the obvious substance for an in vitro comparison of the effectiveness of neonatal suction catheters reported by Ryan et al. They found that the Yankauer and the bulb syringe were much better than any other suction catheter. This should come as no surprise to anyone who has had the misfortune of being offered a pathetic little flexible suction catheter designed for endotracheal use when trying to clear lumps of semi-particulate meconium from a baby's airway. However such objective evidence is often needed when making a case for change in environments such as delivery suites. See page F241
ADC: the fate of the foreskin
Readers of F&N might like to take a look at ‘Male circumcision: risk versus benefit’ in this month’s ADC. Wheeler and Malone consider the effects, and possible harms, of the withdrawal in 2006 of NHS funding for religious or cultural ritual circumcision in England. They make many interesting points, including the fact that the American Academy of Paediatrics has radically changed its stance on circumcision in general, on the grounds that it can no longer be regarded as an intervention devoid of medical benefit. Instead it might be a question of weighing potential benefits against potential harms; in other words, a legitimate healthcare choice as well as a cultural and religious preference, and deserving of NHS funding on the grounds of patient safety. I suspect that the arguments about male genital mutilation will run for a long time yet.