Randomized Trial of Hydrocortisone in Very Preterm High-Risk Infants

Condition(s) targeted: Bronchopulmonary Dysplasia; Encephalomalacia; Premature Birth

Intervention: Hydrocortisone (Drug); Placebo (Drug)

Phase: Phase 2

Status: Recruiting

Sponsored by: The University of Texas Health Science Center, Houston

Official(s) and/or principal investigator(s):
Nehal A. Parikh, D.O., Principal Investigator, Affiliation: University of Texas Health Science Center Medical School at Houston

Overall contact:
Georgia E. McDavid, RN, Phone: 713-500-5734, Email: Georgia.E.Mcdavid@uth.tmc.edu

The purpose of this study is to determine whether treatment of very preterm infants at high-risk for lung and brain injury with low dose hydrocortisone results in improved pulmonary and neurologic outcomes.

Official title: A Randomized Trial of Hydrocortisone in Very Preterm Infants at High Risk for Neurologic and Pulmonary Impairments

Study design: Prevention, Randomized, Double Blind (Subject, Caregiver, Investigator, Outcomes Assessor), Placebo Control, Parallel Assignment, Safety/Efficacy Study

Primary outcome: Total cerebral volume as measured by volumetric brain MRI

Secondary outcome:

Regional brain volumes

Duration of mechanical ventilation

Duration of oxygen requirement

Diagnosis of BPD

Detailed description: Hypothesis: Among extremely low birth weight infants (ELBW; BW ≤ 1000 g) at high risk for bronchopulmonary dysplasia (BPD) and neurologic impairments, those infants randomized to seven days of hydrocortisone will demonstrate increased total cerebral tissue volumes as compared to infants randomized to placebo.

Specific Aims: 1) To perform a pilot blinded randomized controlled trial of a 7-day regimen of low dose hydrocortisone in ELBW infants at high risk for BPD and neurosensory impairments and assess its effect on cerebral tissue volumes. 2) Evaluate and report 2 year neurodevelopmental outcomes.

Background and Significance: Bronchopulmonary dysplasia is a disease of arrested lung development and lung inflammation. It is primarily seen in ELBW infants. Neurological delay, including cerebral palsy and mental retardation, affect up to 40%-50% of surviving ELBW infants. BPD is an important risk factor for such neurological delay. Postnatal administration of corticosteroids to ventilated preterm neonates results in a reduced risk of developing BPD. Postnatal corticosteroids however have shown harmful effects on the brain and can lead to increased rates of cerebral palsy and learning problems. This effect has primarily been seen with dexamethasone when high doses were given in the first week of life. Beyond the first week of life, there is insufficient information on the effects of steroids on the brain. Steroids other than dexamethasone, in much lower doses have been shown to improve short term lung function with minimal short-term side effects. A review study of all steroid trials for BPD shows that when given to a high risk group of infants (> 50% risk of BPD) steroids protect the brain and reduce rates of cerebral palsy. The American and Canadian Pediatric societies and respected researchers have commented on the urgent need for more trials of other corticosteroids at lower doses started after the first week of life to evaluate their short and long-term pulmonary and neurological benefits and risks.

Research Design and Methods:

1. Inclusion & Exclusion Criteria: See below.

2. Procedures: Consented eligible patients will be randomly assigned to receive hydrocortisone in a tapering schedule over 7 days or placebo (comparison group). Study drug will be given every 12 hours IV with only study pharmacist aware of assignment. The patient's anatomic brain MRI (routinely done on all ELBW infants at 38 weeks post-menstrual age) will be further processed by the masked study investigators to derive total and regional brain volumes. Administration of indomethacin or dexamethasone to enrolled infants will be closely monitored and regulated throughout the trial period. Indomethacin use during study period is contraindicated. Dexamethasone (or other steroid) use will be restricted to ELBW infants on high ventilator settings (RIS > 10) after 28 days of life. All other procedures will be per routine care. Blinded developmental follow-up at two years, already currently performed for all ELBW infants at MHCH, will be analyzed and reported for all study infants.

Minimum age: N/A. Maximum age: 3 Weeks. Gender(s): Both.

Criteria:

Inclusion Criteria:

- Patient in the Memorial Hermann Children's Hospital (MHCH) NICU with a birth weight ≤

1000 grams.

- Ventilator-dependent between 10 and 21 days of age.

- Respiratory index score (RIS: mean airway pressure x fraction of inspired oxygen) of ≥

2. 0 that is increasing or stable for the previous 24 hours or a RIS ≥ 3. 0 if improvement noted in the past 24 hours.

Exclusion Criteria:

- Prior postnatal steroid treatment.

- Evidence of sepsis or necrotizing enterocolitis.

- Known major congenital anomalies of the cardiopulmonary or central nervous system.

- Infants being treated with indomethacin or those likely to require treatment in the

next 7 days as judged by the treating physician.

- Inability or unwillingness of parent or legal guardian/representative to give written

informed consent.

- Gestational age < 23 weeks.

Georgia E. McDavid, RN, Phone: 713-500-5734, Email: Georgia.E.Mcdavid@uth.tmc.edu

Memorial Hermann Children's Hospital, Houston, Texas 77030, United States; Recruiting
Marianna Riggs, Phone: 713-704-4256, Email: Marianna_Riggs@mhhs.org
Joy Lilljedahl, MBA, Phone: 713-704-4269, Email: Joy.C.Lilljedahl@uth.tmc.edu
Jon E Tyson, MD, MPH, Sub-Investigator
Kathleen A. Kennedy, MD, MPH, Sub-Investigator
Nehal A. Parikh, D.O., Principal Investigator

Patient information page - Bronchopulmonary Dysplasia

Related publications:

Parikh NA, Lasky RE, Kennedy KA, Moya FR, Hochhauser L, Romo S, Tyson JE. Postnatal dexamethasone therapy and cerebral tissue volumes in extremely low birth weight infants. Pediatrics. 2007 Feb;119(2):265-72.

Starting date: November 2005
Ending date: May 2010
Last updated: October 22, 2008