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Wootton SH, Rysavy M, Davis P, Thio M, Romero-Lopez M, Holzapfel LF, Thrasher T, Wade JD, Owen L. Practical approaches for supporting informed consent in neonatal clinical trials. Acta Paediatr 2024; 113:923-930. [PMID: 38389165 PMCID: PMC11006570 DOI: 10.1111/apa.17165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 01/23/2024] [Accepted: 02/13/2024] [Indexed: 02/24/2024]
Abstract
The survival and health of preterm and critically ill infants have markedly improved over the past 50 years, supported by well-conducted neonatal research. However, newborn research is difficult to undertake for many reasons, and obtaining informed consent for research in this population presents several unique ethical and logistical challenges. In this article, we explore methods to facilitate the consent process, including the role of checklists to support meaningful informed consent for neonatal clinical trials. CONCLUSION: The authors provide practical guidance on the design and implementation of an effective consent checklist tailored for use in neonatal clinical research.
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Affiliation(s)
- Susan H. Wootton
- Division of Infectious Diseases, Department of Pediatrics, McGovern Medical School at UTHealth Houston, Houston, Texas, USA
- Institute for Clinical Research and Learning Health Care, McGovern Medical School at UTHealth Houston, Houston, Texas, USA
- Children's Memorial Hermann Hospital, Houston, Texas, USA
| | - Matthew Rysavy
- Institute for Clinical Research and Learning Health Care, McGovern Medical School at UTHealth Houston, Houston, Texas, USA
- Children's Memorial Hermann Hospital, Houston, Texas, USA
- Division of Neonatology, Department of Pediatrics, McGovern Medical School at UTHealth, Houston, Texas, USA
| | - Peter Davis
- Newborn Research, Neonatal Services, Royal Women's Hospital, Melbourne, Australia
- Department of Obstetrics, Gynaecology and Newborn Health, University of Melbourne, Melbourne, Australia
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Australia
| | - Marta Thio
- Newborn Research, Neonatal Services, Royal Women's Hospital, Melbourne, Australia
- Department of Obstetrics, Gynaecology and Newborn Health, University of Melbourne, Melbourne, Australia
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Australia
- Gandel Simulation Service, Royal Women's Hospital, Melbourne, Australia
| | - Mar Romero-Lopez
- Institute for Clinical Research and Learning Health Care, McGovern Medical School at UTHealth Houston, Houston, Texas, USA
- Children's Memorial Hermann Hospital, Houston, Texas, USA
- Division of Neonatology, Department of Pediatrics, McGovern Medical School at UTHealth, Houston, Texas, USA
| | - Lindsay F. Holzapfel
- Children's Memorial Hermann Hospital, Houston, Texas, USA
- Division of Neonatology, Department of Pediatrics, McGovern Medical School at UTHealth, Houston, Texas, USA
| | - Tamara Thrasher
- Children's Memorial Hermann Hospital, Houston, Texas, USA
- March of Dimes NICU Family Support Program, Houston, Texas, USA
| | - Jaleesa D. Wade
- Division of Neonatology, Department of Pediatrics, McGovern Medical School at UTHealth, Houston, Texas, USA
| | - Louise Owen
- Newborn Research, Neonatal Services, Royal Women's Hospital, Melbourne, Australia
- Department of Obstetrics, Gynaecology and Newborn Health, University of Melbourne, Melbourne, Australia
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Australia
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Jani PR, Maheshwari R, Skelton H, Viola P, Thomas S, Ryder L, Culcer M, Mishra U, Shah S, Baird J, Elhindi J, Padernia AM, Goyen TA, D'Cruz D, Luig M, Shah D. Temperature probe placement in very preterm infants during delivery room stabilization: an open-label randomized trial. Pediatr Res 2024:10.1038/s41390-024-03115-5. [PMID: 38443526 DOI: 10.1038/s41390-024-03115-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 02/01/2024] [Accepted: 02/17/2024] [Indexed: 03/07/2024]
Abstract
BACKGROUND Variation in practice exists for temperature probe positioning during stabilization of very preterm infants (<32 weeks gestation). We explored the influence of temperature probe sites on thermoregulation. METHODS An open-label, stratified, balanced, parallel, randomized trial was conducted. Inborn infants were randomly assigned temperature probe to the axilla or to the upper back. The primary outcome was normothermia (local range: 36.8-37.3 °C and World Health Organization (WHO) range: 36.5-37.5 °C) at admission to the neonatal intensive care unit. RESULTS Between 1 November 2018 and 4 July 2022, 178 infants were randomly assigned to one of the two sites (n = 89 each), 175 included in the final analysis. Normothermia (local range) was achieved for 39/87 infants (44.8%) assigned to the upper back compared to 28/88 infants (31.8%) assigned to the axilla [risk difference:13%; 95% CI -1.3-27.3]. Normothermia (WHO range) was achieved for 78/87 infants (89.7%) assigned to the upper back compared to 70/88 infants (79.6%) assigned to the axilla [risk difference:10.1%; 95% CI -0.5-20.7]. No infant recorded temperatures >38 °C or developed skin injury. CONCLUSIONS In very preterm infants, upper back site was equally effective as the axilla in maintaining normothermia, with no increase in adverse events. CLINICAL TRIAL REGISTRATION The study was registered with the Australian New Zealand Clinical Trials Registry (ACTRN12620000293965). IMPACT Substantial variation in practice exists for the site of securing a temperature probe during delivery room stabilization of very preterm infants and the influence of temperature probe site on thermoregulation remains unknown. In this study, upper back site was equally effective as the axilla in maintaining normothermia, with no increase in adverse events. Clinicians could adopt upper back site for maintaining normothermia. This study may contribute data to future international participant data prospective meta analysis of randomized controlled trials worldwide on temperature probe positioning in very preterm infants, increasing translation of research findings to optimize thermoregulation and clinical outcomes.
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Affiliation(s)
- Pranav R Jani
- Department of Neonatology, Westmead Hospital, Westmead, NSW, Australia.
- The Reproduction and Perinatal Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.
| | - Rajesh Maheshwari
- Department of Neonatology, Westmead Hospital, Westmead, NSW, Australia
- The Reproduction and Perinatal Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Hannah Skelton
- Department of Neonatology, Westmead Hospital, Westmead, NSW, Australia
- School of Nursing and Midwifery, Western Sydney University, Penrith, NSW, Australia
| | - Patricia Viola
- Department of Neonatology, Westmead Hospital, Westmead, NSW, Australia
| | - Sheela Thomas
- Department of Neonatology, Westmead Hospital, Westmead, NSW, Australia
| | - Lynette Ryder
- Department of Maternal and Fetal Medicine, Westmead Hospital, Westmead, NSW, Australia
| | - Mihaela Culcer
- Department of Neonatology, Westmead Hospital, Westmead, NSW, Australia
- The Reproduction and Perinatal Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Umesh Mishra
- Department of Neonatology, Westmead Hospital, Westmead, NSW, Australia
- The Reproduction and Perinatal Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Swapnil Shah
- Department of Neonatology, Westmead Hospital, Westmead, NSW, Australia
- The Reproduction and Perinatal Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Jane Baird
- Department of Neonatology, Westmead Hospital, Westmead, NSW, Australia
| | - James Elhindi
- The Reproduction and Perinatal Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Research and Education Network, Westmead Hospital, Westmead, NSW, Australia
| | | | - Traci-Anne Goyen
- Department of Neonatology, Westmead Hospital, Westmead, NSW, Australia
| | - Daphne D'Cruz
- Department of Neonatology, Westmead Hospital, Westmead, NSW, Australia
| | - Melissa Luig
- Department of Neonatology, Westmead Hospital, Westmead, NSW, Australia
| | - Dharmesh Shah
- Department of Neonatology, Westmead Hospital, Westmead, NSW, Australia
- The Reproduction and Perinatal Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
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Katheria AC, Schmölzer GM, Law B, Yoder BA, Clark E, El-Naggar W, Morales A, Dorner RA, Mooso B, Rich W, Vora F, Finer N. Parental perspectives on a trial using waived informed consent at birth. J Perinatol 2024; 44:415-418. [PMID: 38129598 DOI: 10.1038/s41372-023-01853-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 11/24/2023] [Accepted: 12/07/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVES To determine parental perspectives in a trial with waived consent. STUDY DESIGN Anonymous survey of birth parents with term infants who were randomized using a waiver of consent, administered after infant discharge. RESULTS 121 (11%) survey responses were collected. Of the 121 responding parents 111 (92%) reported that this form of consent was acceptable and 116 (96%) reported feeling comfortable having another child participate in a similar study. 110 (91%) respondents reported that they both understood the information provided in the consent process and had enough time to consider participation. Four percent had a negative opinion on the study's effect on their child's health. CONCLUSIONS Most responding parents reported both acceptability of this study design in the neonatal period and that the study had a positive effect on their child's health. Future work should investigate additional ways to involve parents and elicit feedback on varied methods of pediatric consent.
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Affiliation(s)
- Anup C Katheria
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA, USA.
| | | | - Brenda Law
- University of Alberta, Edmonton, AB, Canada
| | | | - Erin Clark
- University of Utah, Salt Lake City, UT, USA
| | | | - Ana Morales
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA, USA
| | - Rebecca A Dorner
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA, USA
| | - Benjamin Mooso
- University of California at San Diego, San Diego, CA, USA
| | - Wade Rich
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA, USA
| | - Farha Vora
- Loma Linda University, Loma Linda, CA, USA
| | - Neil Finer
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA, USA
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Maiwald CA, Rovers C, Janvier A, Sturm H, Michaelis M, Marckmann G, Ehni HJ, Poets CF, Rüdiger M, Franz AR. Parental perspectives about information and deferred versus two-stage consent in studies of neonatal asphyxia. Arch Dis Child Fetal Neonatal Ed 2023; 109:106-111. [PMID: 37648417 PMCID: PMC10804040 DOI: 10.1136/archdischild-2023-325900] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 08/10/2023] [Indexed: 09/01/2023]
Abstract
OBJECTIVE The ALBINO Trial (NCT03162653) investigates effects of very early postnatal allopurinol on neurocognitive outcome following perinatal asphyxia where prenatal informed consent (IC) is impossible. Ethically and legally, waiver of consent and/or deferred consent (DC) is acceptable in such an emergency. Short oral/two-step consent (SOC, brief information and oral consent followed by IC) has recently been investigated. METHODS Mixed-methods analysis of parental opinions on DC versus SOC in the context of neonatal asphyxia in a survey at two German centres. Prospective parents (ProP), parents of healthy newborns (PNeo) and parents of asphyxiated infants (PAx) born between 2006 and 2016 were invited. RESULTS 108 of 422 parents participated (ProP:43; PNeo:35; PAx:30). Most parents trusted physicians, wanted preinterventional information and agreed that in emergencies interventions should begin immediately. Intergroup and intragroup variability existed for questions about DC and SOC. In the ALBINO Trial situation, 55% preferred SOC, and 26% reported DC without information might adversely affect their trust. Only 3% reported to potentially take legal action after DC. PAx were significantly more likely to support DC. PAx more frequently expressed positive emotions and appreciation for neonatal research. In open-ended questions, parents gave many constructive recommendations. CONCLUSION In this survey, parents expressed diverse opinions on consent, but the majority preferred SOC over DC. Parents who had experienced emergency admission of their asphyxiated neonates were more trusting. Obtaining parental perspectives is essential when designing studies, while being cognisant that these groups of parents may not represent the opinion of all parents.
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Affiliation(s)
- Christian A Maiwald
- Department of Neonatology, University Children's Hospital Tübingen, Tübingen, Baden-Württemberg, Germany
- Center for Pediatric Clinical Studies (CPCS), University Hospital Tübingen, Tübingen, Baden-Württemberg, Germany
| | - Charlotte Rovers
- Department of Neonatology, University Children's Hospital Tübingen, Tübingen, Baden-Württemberg, Germany
| | - Annie Janvier
- Department of Pediatrics, Bureau de l'Éthique Clinique, Université de Montréal, Montreal, Québec, Canada
- Division of Neonatology, Research Center, Clinical Ethics Unit, Palliative Care Unit, Unité de recherche en éthique clinique et partenariat famille, CHU Sainte-Justine, Montreal, Québec, Canada
| | - Heidrun Sturm
- Centre for Public Health and Health Services Research, Faculty of Medicine, University Hospital Tübingen, Tübingen, Baden-Württemberg, Germany
| | - Martina Michaelis
- Centre for Public Health and Health Services Research, Faculty of Medicine, University Hospital Tübingen, Tübingen, Baden-Württemberg, Germany
- Institute of Occupational and Social Medicine and Health Services Research, University Hospital Tübingen, Tübingen, Baden-Württemberg, Germany
| | - Georg Marckmann
- Institute of Ethics, History and Theory of Medicine, Ludwig Maximilians University (LMU) Munich, Munich, Bayern, Germany
| | - Hans-Joerg Ehni
- Institute for Ethics and History of Medicine, Medical Faculty, University of Tübingen, Tübingen, Baden-Württemberg, Germany
| | - Christian F Poets
- Department of Neonatology, University Children's Hospital Tübingen, Tübingen, Baden-Württemberg, Germany
| | - Mario Rüdiger
- Clinic for Pediatrics, Department of Neonatology and Pediatric Intensive Care, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, Dresden, Saxony, Germany
| | - Axel R Franz
- Department of Neonatology, University Children's Hospital Tübingen, Tübingen, Baden-Württemberg, Germany
- Center for Pediatric Clinical Studies (CPCS), University Hospital Tübingen, Tübingen, Baden-Württemberg, Germany
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Shastry A, Bajuk B, Abdel-Latif ME. Are we enrolling representative cohorts of premature infants in our clinical trials? J Perinatol 2022; 42:86-90. [PMID: 34518625 DOI: 10.1038/s41372-021-01204-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 08/16/2021] [Accepted: 08/27/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To compare the difference in outcomes in a subset population of infants "eligible but not enrolled; ENE" vs those who were "eligible and enrolled, EE" in The Australian Placental Transfusion Study (APTS). STUDY DESIGN Population-based multicentre retrospective cohort study. RESULTS A total of 535 (17.7%) infants were categorized as EE and 2489 (82.3%) ENE. ENE infants were significantly more premature (mean gestation 27.0 vs 28.0 weeks) but otherwise of similar anthropometric measures compared to EE infants. ENE infants had significantly higher incidences of low Apgar scores <7 at 5 min, CLD, IVH and PDA requiring treatment. Using a multivariate adjusted-analysis, ENE were at a greater risk for mortality (OR 1.86; 95% CI, 1.30-2.67, p < 0.001). CONCLUSION Antenatal consenting may lead to biased population representation, which may affect trial results' generalizability. Retrospective consent or waiver of consent may improve the generalizability of neonatal and emergency clinical trials.
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Affiliation(s)
- Adithya Shastry
- Medical School, ANU College of Health and Medicine, Australian National University, Acton, ACT, Australia
| | - Barbara Bajuk
- Neonatal Intensive Care Units' (NICUS) Data Registry, Sydney Children's Hospitals Network, Randwick, NSW, Australia
| | - Mohamed E Abdel-Latif
- Medical School, ANU College of Health and Medicine, Australian National University, Acton, ACT, Australia. .,Department of Neonatology, Centenary Hospital for Women and Children, The Canberra Hospital, Garren, ACT, Australia. .,Department of Public Health, La Trobe University, Bundoora, VIC, Australia.
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Abstract
Deferred consent has gained traction in some countries as a possible adjunct to prospective consent for evaluating emergency therapies in the neonatal population. This form of consent has been shown to increase recruitment of acutely and critically unwell patients, potentially reduce parent decision-making burden, and provide more robust evidence for clinical treatments where equipoise exists. However, deferred consent raises complex ethical concerns and guidelines for its use vary across different jurisdictions. The views of all stakeholders, including neonatal providers and parents, are important in determining the appropriateness of deferred consent in high-risk patients. Deferred consent may be ethically justifiable for assessing various treatments, particularly those used in emergency medical management. We present a framework based on neonatal deferred consent trials that assess both non-drug and drug interventions, our experience conducting deferred consent neonatal studies in Australia, and the views of providers and parents on how to best implement deferred consent in the neonatal research setting.
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Higher versus Lower Oxygen Concentration during Respiratory Support in the Delivery Room in Extremely Preterm Infants: A Pilot Feasibility Study. CHILDREN 2021; 8:children8110942. [PMID: 34828655 PMCID: PMC8625238 DOI: 10.3390/children8110942] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 10/07/2021] [Accepted: 10/15/2021] [Indexed: 11/28/2022]
Abstract
Background: Optimal starting oxygen concentration for delivery room resuscitation of extremely preterm infants (<29 weeks) remains unknown, with recommendations of 21–30% based on uncertain evidence. Individual patient randomized trials designed to answer this question have been hampered by poor enrolment. Hypothesis: It is feasible to compare 30% vs. 60% starting oxygen for delivery room resuscitation of extremely preterm infants using a change in local hospital policy and deferred consent approach. Study design: Prospective, single-center, feasibility study, with each starting oxygen concentration used for two months for all eligible infants. Population: Infants born at 23 + 0–28 + 6 weeks’ gestation who received delivery room resuscitation. Study interventions: Initial oxygen at 30% or 60%, increasing by 10–20% every minute for heart rate < 100 bpm, or increase to 100% for chest compressions. Primary outcome: Feasibility, defined by (i) achieving difference in cumulative supplied oxygen concentration between groups, and (ii) post-intervention rate consent >50%. Results: Thirty-four infants were born during a 4-month period; consent was obtained in 63%. Thirty (n = 12, 30% group; n = 18, 60% group) were analyzed, including limited data from eight who died or were transferred before parents could be approached. Median cumulative oxygen concentrations were significantly different between the two groups in the first 5 min. Conclusion: Randomized control trial of 30% or 60% oxygen at the initiation of resuscitation of extremely preterm neonates with deferred consent is feasible. Trial registration: Clinicaltrials.gov NCT03706586
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Sloss S, Dawson JA, McGrory L, Rafferty AR, Davis PG, Owen LS. Observational study of parental opinion of deferred consent for neonatal research. Arch Dis Child Fetal Neonatal Ed 2021; 106:258-264. [PMID: 33127737 DOI: 10.1136/archdischild-2020-319974] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 09/11/2020] [Accepted: 09/29/2020] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To evaluate the opinions of parents of newborns following their infant's enrolment into a neonatal research study through the process of deferred consent. DESIGN Mixed-methods, observational study, interviewing 100 parents recently approached for deferred consent. SETTING Tertiary-level neonatal intensive care unit, Melbourne, Australia. RESULTS All 100 parents interviewed had consented to the study/studies using deferred consent; 62% had also experienced a prospective neonatal consent process. Eighty-nine per cent were 'satisfied' with the deferred consent process. The most common reason given for consenting was 'to help future babies'. Negative comments regarding deferred consent mostly related to the timing of the consent approach, and some related to a perceived loss of parental rights. A deferred approach was preferred by 51%, 24% preferred a prospective approach and 25% were unsure. Those who thought prospective consent would not have been preferable cited impaired decision-making, inappropriate timing of an approach before birth and their preference for removal of the decision-making burden via deferred consent. Seventy-seven per cent thought they would have given the same response if approached prospectively; those who would have declined reported that a prospective approach under stressful conditions was unwelcome and too overwhelming. CONCLUSION In our sample, 89% of parents of infants enrolled in neonatal research using deferred consent considered it acceptable and half would not have preferred prospective consent. The ability to make a more considered decision under less stressful circumstances was key to the acceptability of deferred consent.
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Affiliation(s)
- Samantha Sloss
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Victoria, Australia
| | - Jennifer Anne Dawson
- Newborn Research, Royal Women's Hospital, Parkville, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Lorraine McGrory
- Newborn Research, Royal Women's Hospital, Parkville, Victoria, Australia
| | | | - Peter G Davis
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Victoria, Australia.,Newborn Research, Royal Women's Hospital, Parkville, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Louise S Owen
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Victoria, Australia .,Newborn Research, Royal Women's Hospital, Parkville, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia
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9
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Owen LS, Davis PG. Parental consent and neonatal delivery room trials: walking an ethical tightrope. Arch Dis Child Fetal Neonatal Ed 2021; 106:116-117. [PMID: 33436447 DOI: 10.1136/archdischild-2020-319355] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 12/17/2020] [Accepted: 12/29/2020] [Indexed: 11/03/2022]
Affiliation(s)
- Louise S Owen
- Dept of Obstetrics and Gynaecology, University of Melbourne, Parkville, Victoria, Australia .,Clinical Sciences, Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Newborn Research, The Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Peter G Davis
- Dept of Obstetrics and Gynaecology, University of Melbourne, Parkville, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Newborn Research, The Royal Women's Hospital, Melbourne, Victoria, Australia
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10
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den Boer MC, Houtlosser M, Foglia EE, Lopriore E, de Vries MC, Engberts DP, Te Pas AB. Deferred consent for delivery room studies: the providers' perspective. Arch Dis Child Fetal Neonatal Ed 2020; 105:310-315. [PMID: 31427459 DOI: 10.1136/archdischild-2019-317280] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 07/22/2019] [Accepted: 08/03/2019] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To gain insight into neonatal care providers' perceptions of deferred consent for delivery room (DR) studies in actual scenarios. METHODS We conducted semistructured interviews with 46 neonatal intensive care unit (NICU) staff members of the Leiden University Medical Center (the Netherlands) and the Hospital of the University of Pennsylvania (USA). At the time interviews were conducted, both NICUs conducted the same DR studies, but differed in their consent approaches. Interviews were audio-recorded, transcribed and analysed using the qualitative data analysis software Atlas.ti V.7.0. RESULTS Although providers reported to regard the prospective consent approach as the most preferable consent approach, they acknowledged that a deferred consent approach is needed for high-quality DR management. However, providers reported concerns about parental autonomy, approaching parents for consent and ethical review of study protocols that include a deferred consent approach. Providers furthermore differed in perceived appropriateness of a deferred consent approach for the studies that were being conducted at their NICUs. Providers with first-hand experience with deferred consent reported positive experiences that they attributed to appropriate communication and timing of approaching parents for consent. CONCLUSION Insight into providers' perceptions of deferred consent for DR studies in actual scenarios suggests that a deferred consent approach is considered acceptable, but that actual usage of the approach for DR studies can be improved on.
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Affiliation(s)
- Maria C den Boer
- Division of Neonatology, Leiden University Medical Center, Leiden, Netherlands .,Department of Medical Ethics and Health Law, Leiden University Medical Center, Leiden, Netherlands
| | - Mirjam Houtlosser
- Department of Medical Ethics and Health Law, Leiden University Medical Center, Leiden, Netherlands
| | - Elizabeth E Foglia
- Division of Neonatology, Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Enrico Lopriore
- Division of Neonatology, Leiden University Medical Center, Leiden, Netherlands
| | - Martine Charlotte de Vries
- Department of Medical Ethics and Health Law, Leiden University Medical Center, Leiden, Netherlands.,Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Dirk P Engberts
- Department of Medical Ethics and Health Law, Leiden University Medical Center, Leiden, Netherlands
| | - Arjan B Te Pas
- Division of Neonatology, Leiden University Medical Center, Leiden, Netherlands
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11
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Kirpalani H, Ratcliffe SJ, Keszler M, Davis PG, Foglia EE, te Pas A, Fernando M, Chaudhary A, Localio R, van Kaam AH, Onland W, Owen LS, Schmölzer GM, Katheria A, Hummler H, Lista G, Abbasi S, Klotz D, Simma B, Nadkarni V, Poulain FR, Donn SM, Kim HS, Park WS, Cadet C, Kong JY, Smith A, Guillen U, Liley HG, Hopper AO, Tamura M. Effect of Sustained Inflations vs Intermittent Positive Pressure Ventilation on Bronchopulmonary Dysplasia or Death Among Extremely Preterm Infants: The SAIL Randomized Clinical Trial. JAMA 2019; 321:1165-1175. [PMID: 30912836 PMCID: PMC6439695 DOI: 10.1001/jama.2019.1660] [Citation(s) in RCA: 101] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Preterm infants must establish regular respirations at delivery. Sustained inflations may establish lung volume faster than short inflations. OBJECTIVE To determine whether a ventilation strategy including sustained inflations, compared with standard intermittent positive pressure ventilation, reduces bronchopulmonary dysplasia (BPD) or death at 36 weeks' postmenstrual age without harm in extremely preterm infants. DESIGN, SETTING, AND PARTICIPANTS Unmasked, randomized clinical trial (August 2014 to September 2017, with follow-up to February 15, 2018) conducted in 18 neonatal intensive care units in 9 countries. Preterm infants 23 to 26 weeks' gestational age requiring resuscitation with inadequate respiratory effort or bradycardia were enrolled. Planned enrollment was 600 infants. The trial was stopped after enrolling 426 infants, following a prespecified review of adverse outcomes. INTERVENTIONS The experimental intervention was up to 2 sustained inflations at maximal peak pressure of 25 cm H2O for 15 seconds using a T-piece and mask (n = 215); standard resuscitation was intermittent positive pressure ventilation (n = 211). MAIN OUTCOME AND MEASURES The primary outcome was the rate of BPD or death at 36 weeks' postmenstrual age. There were 27 prespecified secondary efficacy outcomes and 7 safety outcomes, including death at less than 48 hours. RESULTS Among 460 infants randomized (mean [SD] gestational age, 25.30 [0.97] weeks; 50.2% female), 426 infants (92.6%) completed the trial. In the sustained inflation group, 137 infants (63.7%) died or survived with BPD vs 125 infants (59.2%) in the standard resuscitation group (adjusted risk difference [aRD], 4.7% [95% CI, -3.8% to 13.1%]; P = .29). Death at less than 48 hours of age occurred in 16 infants (7.4%) in the sustained inflation group vs 3 infants (1.4%) in the standard resuscitation group (aRD, 5.6% [95% CI, 2.1% to 9.1%]; P = .002). Blinded adjudication detected an imbalance of rates of early death possibly attributable to resuscitation (sustained inflation: 11/16; standard resuscitation: 1/3). Of 27 secondary efficacy outcomes assessed by 36 weeks' postmenstrual age, 26 showed no significant difference between groups. CONCLUSIONS AND RELEVANCE Among extremely preterm infants requiring resuscitation at birth, a ventilation strategy involving 2 sustained inflations, compared with standard intermittent positive pressure ventilation, did not reduce the risk of BPD or death at 36 weeks' postmenstrual age. These findings do not support the use of ventilation with sustained inflations among extremely preterm infants, although early termination of the trial limits definitive conclusions. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT02139800.
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Affiliation(s)
- Haresh Kirpalani
- Division of Neonatology, Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia
| | - Sarah J. Ratcliffe
- Division of Biostatistics, Department of Public Health Sciences, University of Virginia, Charlottesville
| | - Martin Keszler
- Warren Alpert Medical School, Department of Pediatrics, Brown University Women and Infants Hospital of Rhode Island, Providence
| | - Peter G. Davis
- Newborn Research Centre, The Royal Women’s Hospital, Melbourne, Victoria, Australia
| | - Elizabeth E. Foglia
- Division of Neonatology, Department of Pediatrics, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Arjan te Pas
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, the Netherlands
| | - Melissa Fernando
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Aasma Chaudhary
- Division of Neonatology, Department of Pediatrics, Children’s Hospital of Philadelphia, Hospital of the University of Pennsylvania, Philadelphia
| | - Russell Localio
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Anton H. van Kaam
- Department of Neonatology, Emma Children’s Hospital, Academic Medical Center, Amsterdam, the Netherlands
| | - Wes Onland
- Department of Neonatology, Emma Children’s Hospital, Academic Medical Center, Amsterdam, the Netherlands
| | - Louise S. Owen
- Newborn Research Center and Neonatal Services, The Royal Women’s Hospital, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynecology, The University of Melbourne, Melbourne, Victoria, Australia
- Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
| | - Georg M. Schmölzer
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Anup Katheria
- Department of Neonatology, Sharp Mary Birch Hospital for Women and Newborns, San Diego, California
| | - Helmut Hummler
- Division of Neonatology, Department of Pediatrics, Sidra Medicine, Doha, Qatar
- Division of Neonatology and Pediatric Critical Care, Department of Pediatrics and Adolescent Medicine, Ulm University, Ulm, Germany
| | - Gianluca Lista
- Department of Pediatrics, NICU, Ospedale dei Bambini V. Buzzi, ASST-FBF-Sacco, Milan, Italy
| | - Soraya Abbasi
- Division of Newborn Pediatrics, Pennsylvania Hospital, Philadelphia
| | - Daniel Klotz
- Center for Pediatrics, Medical Center–University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Burkhard Simma
- Department of Pediatrics, Academic Teaching Hospital, Landeskrankenhaus Feldkirch, Feldkirch, Austria
| | - Vinay Nadkarni
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Francis R. Poulain
- Division of Neonatology, Department of Pediatrics, University of California, Davis, Sacramento
| | - Steven M. Donn
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, C.S. Mott Children’s Hospital, Michigan Medicine, University of Michigan, Ann Arbor
| | - Han-Suk Kim
- Division of Neonatology, Department of Pediatrics, Seoul National University Children’s Hospital, Seoul, Republic of Korea
| | - Won Soon Park
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Claudia Cadet
- Department of Neonatology, WakeMed Health and Hospitals, Raleigh, North Carolina
| | - Juin Yee Kong
- Department of Neonatology, KK Women’s and Children’s Hospital, Singapore
| | - Alexandra Smith
- Department of Pediatrics, Tufts Clinical and Translational Research Institute, The Floating Hospital for Children at Tufts Medical Center, Boston, Massachusetts
| | | | - Helen G. Liley
- Newborn Services, Mater Mothers’ Hospital and Mater Research, South Brisbane, Queensland, Australia
| | - Andrew O. Hopper
- Division of Neonatology, Department of Pediatrics, Loma Linda University, Loma Linda, California
| | - Masanori Tamura
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
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Rich WD, Katheria AC. Waived Consent in Perinatal/Neonatal Research-When Is It Appropriate? Front Pediatr 2019; 7:493. [PMID: 31850290 PMCID: PMC6901905 DOI: 10.3389/fped.2019.00493] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 11/12/2019] [Indexed: 11/18/2022] Open
Abstract
Informed consent is a process ensuring that subjects enrolled in research are appropriately informed of the risks and benefits. While this process is well-defined when it is possible and practical to obtain consent prior to the research intervention, it can be less clear in cases of deferred or waived consent. Defining minimal risk, such as when research is attempting to determine which of two currently practiced interventions is safest and/or most effective, is critical to moving forward in establishing appropriate care in newborns. For perinatal/neonatal research the challenge lies between the ethical justification for approaching women in labor or under medication vs. the scientific integrity of excluding a number of subjects that may potentially benefit the most from an intervention. Researchers must work with their IRBs as well as families who have participated in trials to determine the most appropriate method for obtaining informed consent from expectant parents. Clinical researchers and IRBs ultimately need to find a middle ground for the appropriate use of deferred or waived consent.
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Affiliation(s)
- Wade D Rich
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA, United States
| | - Anup C Katheria
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA, United States
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13
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Songstad NT, Roberts CT, Manley BJ, Owen LS, Davis PG. Retrospective Consent in a Neonatal Randomized Controlled Trial. Pediatrics 2018; 141:peds.2017-2092. [PMID: 29288162 DOI: 10.1542/peds.2017-2092] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/03/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The requirement for prospective consent in clinical trials in acute settings may result in samples unrepresentative of the study population, potentially altering study findings. However, using retrospective consent may raise ethical issues. We assessed whether using retrospective consent affected recruitment, participant characteristics, and outcomes within a randomized controlled trial. METHODS We conducted a secondary analysis of a randomized trial, which compared nasal high flow (nHF) with nasal continuous positive airway pressure (CPAP) for primary respiratory support in preterm infants. In Era 1, all infants were consented prospectively; in Era 2, retrospective consent was available. We assessed inclusion rates of eligible infants, demographic data, and primary trial outcome (treatment failure within 72 hours). RESULTS In Era 1, recruitment of eligible infants was lower than in Era 2: 111 of 220 (50%) versus 171 of 209 (82%), P < .001; intrapartum antibiotic administration was lower: 23 of 111 (21%) versus 84 of 165 (51%), P < .001; full courses of antenatal steroids were higher: 86 of 111 (78%) versus 103 of 170 (61%), P = .004; and more infants received pre-randomization CPAP: 77 of 111 (69%) versus 48 of 171 (28%), P < .001. In Era 1, nHF failure (15 of 56, 27%) and CPAP failure (14 of 55, 26%) rates were similar, P = .9. In Era 2, failure rates differed: 24 of 85 (28%) nHF infants versus 13 of 86 (15%) CPAP infants, P = .04. The χ2 interaction test was nonsignificant (P = .20). CONCLUSIONS The use of retrospective consent resulted in greater recruitment and differences in risk factors between eras. Using retrospective consent altered the study sample, which may be more representative of the whole population. This may improve scientific validity but requires further ethical evaluation.
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Affiliation(s)
- Nils T Songstad
- Newborn Research Centre and .,Department of Pediatrics and Adolescent Medicine, University Hospital of North Norway, Tromsø, Norway
| | - Calum T Roberts
- Newborn Research Centre and.,Neonatal Services, The Royal Women's Hospital, Melbourne, Australia.,Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Australia; and
| | - Brett J Manley
- Newborn Research Centre and.,Neonatal Services, The Royal Women's Hospital, Melbourne, Australia.,Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Australia; and
| | - Louise S Owen
- Newborn Research Centre and.,Neonatal Services, The Royal Women's Hospital, Melbourne, Australia.,Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Australia; and.,Murdoch Children's Research Institute, Melbourne, Australia
| | - Peter G Davis
- Newborn Research Centre and.,Neonatal Services, The Royal Women's Hospital, Melbourne, Australia.,Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Australia; and.,Murdoch Children's Research Institute, Melbourne, Australia
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14
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Harvey M, Nongena P, Edwards D, Redshaw M. 'We knew it was a totally at random thing': parents' experiences of being part of a neonatal trial. Trials 2017; 18:361. [PMID: 28764800 PMCID: PMC5539623 DOI: 10.1186/s13063-017-2112-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 07/18/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Studies exploring parents' trial experiences generally relate to their understanding of the consent process and the development of researcher strategies to facilitate recruitment and retention. The aim was to better understand parents' experience of being part of a trial at the time and their perceptions of trial participation in retrospect. METHODS Data were collected in a number of ways: from recorded discussions between parents and clinicians about the MRI or ultrasound, in open-text responses to questionnaires and in qualitative interviews at 1 and 2 years after participation. Thematic analysis was undertaken using NVivo10. RESULTS Key themes identified were 'deciding to take part', with subthemes associated with 'benefitting self', 'benefitting others' and 'being prepared'; 'the randomisation process' with subthemes relating to 'acceptance' and 'understanding' and 'actual engagement' with subthemes of 'practicalities' and 'care from responsive staff'. CONCLUSION Parents' perspectives on the trial and the processes and information received reflect their understanding and experience of the trial and the value of parent-friendly information-giving about participation, randomisation and follow-up. The practical and logistical points raised confirm the key issues and parents' need for sensitive care and support in the course of a trial. Looking back, almost all parents were positive about their experience and felt that the family had benefitted from participation in the trial and follow-up studies, even when the developmental outcomes were poor. TRIAL REGISTRATION ClinicalTrials.gov, ID: NCT01049594. https://clinicaltrials.gov/ct2/show/NCT01049594 . Registered on 13 January 2010. EudraCT: EudraCT: 2009-011602-42. https://www.clinicaltrialsregister.eu/ .
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Affiliation(s)
- Merryl Harvey
- Centre for the Developing Brain, Division of Imaging and Biomedical Engineering, King's College, London, UK.,National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Old Road, Oxford, OX3 7LF, UK.,Faculty of Health, Education and Life Sciences, Birmingham City University, Birmingham, UK
| | - Phumza Nongena
- Centre for the Developing Brain, Division of Imaging and Biomedical Engineering, King's College, London, UK.,Department of Paediatrics, Walter Sisulu University, Cecelia Makiwane Hospital, Mdantsane, East London, South Africa
| | - David Edwards
- Centre for the Developing Brain, Division of Imaging and Biomedical Engineering, King's College, London, UK
| | - Maggie Redshaw
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Old Road, Oxford, OX3 7LF, UK.
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