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What do you want to do today?:
Picking outcomes is extremely important. This month, we have three neonatally focused Archimedes topics. They come up with clinical bottom lines which may surprise, annoy, or bore the reader. Take the subject of lumbar punctures in neonates; performing them—or avoiding them. If you have a strong opinion about this topic it is likely to be drawn from years (well, months) of experience, seeing babies doing generally very well with/without a spinal tap, and deciding that your course of action is likely to be the most beneficial. Malbon et al argue that all babies with suspected sepsis should undergo a lumbar puncture “to diagnose meningitis”. What if they had chosen instead to ask instead “to prevent neuropsychological disability”? Or if they had asked whether the undertaking, or avoiding, of spinal taps makes families more or less anxious? Would the clinical bottom line be the same?
Similar suggestions can be made about our other two topics: Does improving weight gain and calorie intake matter over the short time frame of insulin infusions versus calorie restriction, or is the important outcome weight at discharge from the neonatal unit, or neurodisability at 1 year? When it comes to intubation, does data from careful studies, with practitioners primed in the use of anaesthetic agents, translate into everyday life on a neonatal unit?
We all ask specific questions, focusing on specific outcomes. It is interesting to pose slightly different questions to each query we have, to challenge our assumptions and test out different perspectives. For one clinician, diagnosing meningitis may be an important end in itself. To another, the nature of a septic episode may be far less important than the proven outcomes. The process of evidence based practice will never bring these two together, but it may make transparent where the argument should focus.
“Be careful what you wish for, it might come true” may be a warning we take away when asking any clinical question. What do we really want to do today?