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

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.

Study Type: Interventional

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

Study Primary Completion Date: September 2008

Hypothesis: Among extremely low birth weight infants (ELBW; BW ≤ 1000g) 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 increase 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.

Intervention(s) in this Clinical Trial

• Drug: Hydrocortisone
  • Hydrocortisone 3 mg/kg/d divided q 12h IV/PO tapered over 7 days

Arms, Groups and Cohorts in this Clinical Trial

• Experimental: 1
  • 1. Tapering dose of hydrocortisone q 12h over 7 day period
• Placebo Comparator: 2
  • 2. Identical-appearing saline placebo

Primary Measures

• Total cerebral volume as measured by volumetric brain MRI at 38 weeks post-menstrual age.
  • Time Frame: 38 weeks post-menstrual age
    Safety Issue?: Yes

Secondary Measures

• Regional brain volumes
  • Time Frame: 38-weeks post-menstrual age
    Safety Issue?: Yes
• Duration of mechanical ventilation
  • Time Frame: NICU hospital stay
    Safety Issue?: No
• Duration of oxygen requirement
  • Time Frame: NICU hosptial stay
    Safety Issue?: No
• Diagnosis of BPD
  • Time Frame: 36 weeks post-menstrual age
    Safety Issue?: No

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 oxy-gen) 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.

Gender Eligibility for this Clinical Trial: Both

Minimum Age for this Clinical Trial: N/A

Maximum Age for this Clinical Trial: 3 Weeks

Are Healthy Volunteers Accepted for this Clinical Trial?: No

Lead Sponsor: The University of Texas Health Science Center, Houston

Overall Clinical Trial Officials and Contacts

Nehal A. Parikh, D.O. Principal Investigator University of Texas Health Science Center Medical School at Houston  

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

Information obtained from ClinicalTrials.gov on October 15, 2008

Link to the current ClinicalTrials.gov record. http://clinicaltrials.gov/show/NCT00167544

Study ID Number: K23NS048152-2

ClinicalTrials.gov Identifier: NCT00167544

Health Authority: United States: Institutional Review Board

Patient information page - Bronchopulmonary Dysplasia