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death follows the withdrawal of ventilatory support, however, you could argue that death must be the intended result and not merely a side effect of acting in the patient's best interests. This is because paralysing drugs suppress a patient's breathing for some time after an infusion has been stopped. Because the patient completely depends on the ventilator she dies quickly when it is withdrawn. The BMA suggests that withdrawing respiratory support in these circumstances could be interpreted in law as an intended killing. 3The doctrine of double effect is difficult to apply in this case, not impossible. To avoid confusion it is necessary to deal with each decision in turn. The first decision-to use muscle relaxants-itself has dual effects, the intended one being to make ventilation possible, and the side effect being to make the patient completely dependent on it. The second decision-to withdraw ventilation-has the effect that the patient dies quickly, but this doesn't have to be the intended effect. The two decisions are morally independent, despite being chronologically and logically sequential, because the intention behind the first decision (to make ventilation possible) is not linked to the side effect of the second, the patient dies. This could be an accurate description of the doctor's intentions in the face of difficult circumstances. It could also provide a legal defence against the charge of murder, although I know of no case law testing this interpretation.The alternative would be either to continue respiratory support indefinitely or to stop the paralysing drugs first and wait for any effects to wear off completely before withdrawing ventilation. The first is arguably not in the patient's best interests. The other may prolong the patient's suffering and that of her parents because of the delay between deciding to withdraw life prolonging treatment and actually doing it. The only reason why muscle relaxants were used in the first place was to allow ventilatory support, so the intention behind withdrawing it can only be to allow the subsequent withdrawal of ventilation, thereby linking the intention of the first decision with the effect of the second. The patient may become distressed and, without the effect of the muscle relaxants, the ventilator may not work properly anyway. It is difficult to see how withdrawing muscle relaxants can be in a patient's best interests without taking him or her off the ventilator at the same time.In any case there are drugs, such as atracurium, that do not have these problematic residual effects, making this particular moral difficulty disappear.

WHAT'S KNOWN ON THIS SUBJECT: Preterm infants dependent on parenteral nutrition are vulnerable to deficits in early postnatal nutritional intake. This coincides with a period of suboptimal head growth. Observational studies indicate that poor nutritional intake is associated with suboptimal head growth and neurodevelopmental outcome. WHAT THIS STUDY ADDS:This study provides randomized controlled trial evidence that head growth failure in the first 4 weeks of life can be ameliorated with early nutritional intervention. Early macronutrient intake can be enhanced by optimizing a standardized, concentrated neonatal parenteral nutrition regimen. abstract BACKGROUND: Early postnatal head growth failure is well recognized in very preterm infants (VPIs). This coincides with the characteristic nutritional deficits that occur in these parenteral nutrition (PN) dependent infants in the first month of life. Head circumference (HC) is correlated with brain volume and later neurodevelopmental outcome. We hypothesized that a Standardized, Concentrated With Added Macronutrients Parenteral (SCAMP) nutrition regimen would improve early head growth. The aim was to compare the change in HC (DHC) and HC SD score (DSDS) achieved at day 28 in VPIs randomly assigned to receive SCAMP nutrition or a control standardized, concentrated PN regimen. METHODS:Control PN (10% glucose, 2.8 g/kg per day protein/lipid) was started within 6 hours of birth. VPIs (birth weight ,1200 g; gestation ,29 weeks) were randomly assigned to either start SCAMP (12% glucose, 3.8 g/kg per day protein/lipid) or remain on the control regimen. HC was measured weekly. Actual daily nutritional intake data were collected for days 1 to 28.RESULTS: There were no differences in demographic data between SCAMP (n = 74) and control (n = 76) groups. Comparing cumulative 28-day intakes, the SCAMP group received 11% more protein and 7% more energy. The SCAMP group had a greater DHC at 28 days (P , .001). The difference between the means (95% confidence interval) for DHC was 5 mm (2 to 8), and DSDS was 0.37 (0.17 to 0.58). HC differences are still apparent at 36 weeks' corrected gestational age. Dr Morgan developed the original concept and designed the study, ensured regulatory approvals, performed some study measurements, data collection and collation, coordinated data analysis, and drafted the initial manuscript; Mr McGowan performed most of the study measurements, data collection, and collation, contributed to data analysis and made study design modifications; Mr Herwitker was involved with study design and regulatory approval, overseeing study PN manufacture, and some data collation; Ms Hart provided the medical statistical support at the design, monitoring, and analytical stages of the study; Dr Turner was involved in study design and data analysis; and all authors approved the final manuscript as submitted. CONCLUSIONS:This trial has been registered with the ISRCTN Register (http:// isrctn.org) (identifier ISRCTN76597892 Improved survival of very preterm infants (VPIs) ha...

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