Ethical considerations for using alternative methods of consent in neonatal clinical trials: recommendations from a modified Delphi consensus process

IMPORTANCE: Neonatal clinical trials frequently encounter low enrolment rates, challenges obtaining consent and biased research populations. Alternative approaches to consent have been proposed to address these concerns but introduce complex ethical trade-offs. OBJECTIVE: Using a modified Delphi approach with diverse stakeholders, we aimed to create recommendations for the use of alternative methods of consent in neonatal clinical trials. FINDINGS: Our process resulted in 21 recommendations within three categories. In 'deciding whether to use alternative methods of consent', we present five statements to guide whether alternative methods are appropriate. For example, heightened justification may be required for early phase research or allocation arms that are highly preference-sensitive for families. In 'preallocation information and ability to opt-out', we present 11 statements related to information sharing with families of potential participants. These include guidance on researcher communication and guidance for passive information sharing such as via flyers. In 'postallocation information and decision to continue participation', we present five statements to guide later information sharing. These focus on best practices for researcher communication postallocation. For two items, our Working Group could not reach consensus. These items were not included in our recommendations. CONCLUSIONS AND RELEVANCE: Our recommendations may guide researchers, clinicians, regulators and funders in the consideration and conduct of alternative methods of consent for neonatal clinical trials. Future work must evaluate these recommendations within neonatal clinical trials and the areas of lack of consensus among our Working Group.