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Clinical Trial Details — Status: Completed

Administrative data

NCT number NCT01475357
Other study ID # HR 20394
Secondary ID
Status Completed
Phase N/A
First received October 6, 2011
Last updated October 14, 2014
Start date October 2011
Est. completion date April 2014

Study information

Verified date October 2014
Source Medical University of South Carolina
Contact n/a
Is FDA regulated No
Health authority United States: Institutional Review Board
Study type Interventional

Clinical Trial Summary

Postnatal intestinal function in cardiac infants. The overall goal of this proposal is to address a widespread health problem in the pediatric cardiac infant population - poor postnatal growth - through a collaborative effort between pediatric cardiology, cardiothoracic surgery, neonatology, microbiology, and immunology. The hypothesis is that term neonates with complex congenital heart disease (CHD) who receive trophic breastmilk feeds in the pre-operative period will show improved gut function than neonates who were strictly NPO (nothing by mouth) in the pre-operative period.


Description:

The overall goal of this proposal is to address a widespread health problem in the pediatric cardiac infant population - poor postnatal growth - through a collaborative effort between pediatric cardiology, cardiothoracic surgery, neonatology, microbiology, and immunology. The foundational hypothesis of this proposal is that term neonates (≥ 37 weeks gestation) with complex congenital heart disease (CHD) are vulnerable to disturbances in intestinal mucosal function, permeability, microflora, and local immune function, which ultimately result in feeding intolerance and poor somatic growth. By identifying biologic targets for perioperative intestinal protection, this project has the potential to shift and improve the paradigm of perioperative care for neonates with complex CHD. This pilot study will generate the data necessary to pursue K23 and R01 funding to further investigate postnatal intestinal maturation and function in neonates with complex CHD and cyanosis, specifically as it pertains to local immune function and inflammatory response.

The objectives of this proposal are to perform a single-center (MUSC), prospective, randomized pilot trial to investigate postnatal intestinal function in cardiac infants through the following Specific Aims:

Specific Aim 1: To compare the decrease in intestinal permeability as determined by urine lactulose: mannitol ratios of the trophic breastmilk fed group (intervention) vs. NPO (nothing by mouth) group (current care) amongst neonates with complex CHD over 3 different time points (postnatal day 3-4, post-operative day 7-8, and post-operative day 13-14).

H1: Infants who receive trophic breastmilk feeds in the pre-operative period will demonstrate a more rapid decrease in intestinal permeability (improved postnatal intestinal maturation) over the first 2 weeks of life compared to those infants who were strictly NPO in the pre-operative period.

Specific Aim 2: To compare the duration (in days) until goal enteral feeds are successfully achieved in the trophic breastmilk fed group vs. NPO group.

H1: Infants who receive trophic breastmilk feeds in the pre-operative period will successfully achieve goal enteral feeds in a shorter duration of time compared to those infants who were strictly NPO in the pre-operative period.

Specific Aim 3: To qualitatively compare the intestinal microflora pattern over the first postpartum month as determined by stool microbiota of the trophic breastmilk fed group vs. NPO group.

H1: The microbiota patterns of those infants who receive trophic breastmilk feeds in the pre-operative period will differ from those infants who were strictly NPO in the pre-operative period.


Recruitment information / eligibility

Status Completed
Enrollment 27
Est. completion date April 2014
Est. primary completion date March 2014
Accepts healthy volunteers No
Gender Both
Age group 37 Weeks to 40 Weeks
Eligibility Inclusion Criteria:

- Study subjects will be male and female neonates admitted to MUSC PCICU or NICU prior to 72 hours of life who are gestational age = 37 weeks.

- inpatient status at MUSC for a minimum of 48 hours prior to planned surgery and have a postnatal diagnosis of complex congenital heart disease - defined as a structural heart defect requiring cardiac surgery (reparative or palliative) prior to hospital discharge.

Exclusion Criteria:

- Infants with hemodynamic instability in the pre-operative period requiring mechanical circulatory support or

- who have the presence of lactate > 3 after the first 24 hours of admission

- admission from home

- major congenital extracardiac abnormalities (i.e. renal, brain, GI)

- cardiac surgery will not be performed at MUSC, and

- mother does not plan to pump breastmilk during the infant's first week of life.

Study Design

Allocation: Randomized, Endpoint Classification: Efficacy Study, Intervention Model: Parallel Assignment, Masking: Open Label, Primary Purpose: Treatment


Intervention

Other:
Arm 1: NPO by mouth pre-operative
Current treatment for infants born with cardiac defects awaiting surgery is to keep them NPO pre-operatively. Arm 1 will make no changes to this current policy.
Arm 2: Fresh Breast Milk pre-operative
Infants randomized to Arm 2 of the study will receive their mother's own breast milk pre-operatively.

Locations

Country Name City State
United States Medical University of South Carolina Charleston South Carolina

Sponsors (1)

Lead Sponsor Collaborator
Medical University of South Carolina

Country where clinical trial is conducted

United States, 

References & Publications (40)

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Clark JA, Doelle SM, Halpern MD, Saunders TA, Holubec H, Dvorak K, Boitano SA, Dvorak B. Intestinal barrier failure during experimental necrotizing enterocolitis: protective effect of EGF treatment. Am J Physiol Gastrointest Liver Physiol. 2006 Nov;291(5):G938-49. Epub 2006 Jun 22. — View Citation

Clark JA, Lane RH, Maclennan NK, Holubec H, Dvorakova K, Halpern MD, Williams CS, Payne CM, Dvorak B. Epidermal growth factor reduces intestinal apoptosis in an experimental model of necrotizing enterocolitis. Am J Physiol Gastrointest Liver Physiol. 2005 Apr;288(4):G755-62. Epub 2004 Nov 4. — View Citation

del Castillo SL, McCulley ME, Khemani RG, Jeffries HE, Thomas DW, Peregrine J, Wells WJ, Starnes VA, Moromisato DY. Reducing the incidence of necrotizing enterocolitis in neonates with hypoplastic left heart syndrome with the introduction of an enteral feed protocol. Pediatr Crit Care Med. 2010 May;11(3):373-7. doi: 10.1097/PCC.0b013e3181c01475. — View Citation

del Castillo SL, Moromisato DY, Dorey F, Ludwick J, Starnes VA, Wells WJ, Jeffries HE, Wong PC. Mesenteric blood flow velocities in the newborn with single-ventricle physiology: modified Blalock-Taussig shunt versus right ventricle-pulmonary artery conduit. Pediatr Crit Care Med. 2006 Mar;7(2):132-7. — View Citation

Dvorak B, Khailova L, Clark JA, Hosseini DM, Arganbright KM, Reynolds CA, Halpern MD. Comparison of epidermal growth factor and heparin-binding epidermal growth factor-like growth factor for prevention of experimental necrotizing enterocolitis. J Pediatr Gastroenterol Nutr. 2008 Jul;47(1):11-8. doi: 10.1097/MPG.0b013e3181788618. — View Citation

Dvorak B. Milk epidermal growth factor and gut protection. J Pediatr. 2010 Feb;156(2 Suppl):S31-5. doi: 10.1016/j.jpeds.2009.11.018. Review. — View Citation

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Harrison AM, Davis S, Reid JR, Morrison SC, Arrigain S, Connor JT, Temple ME. Neonates with hypoplastic left heart syndrome have ultrasound evidence of abnormal superior mesenteric artery perfusion before and after modified Norwood procedure. Pediatr Crit Care Med. 2005 Jul;6(4):445-7. — View Citation

He F, Morita H, Ouwehand AC, Hosoda M, Hiramatsu M, Kurisaki J, Isolauri E, Benno Y, Salminen S. Stimulation of the secretion of pro-inflammatory cytokines by Bifidobacterium strains. Microbiol Immunol. 2002;46(11):781-5. — View Citation

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Kelleher DK, Laussen P, Teixeira-Pinto A, Duggan C. Growth and correlates of nutritional status among infants with hypoplastic left heart syndrome (HLHS) after stage 1 Norwood procedure. Nutrition. 2006 Mar;22(3):237-44. — View Citation

Klagsbrun M. Nutrition Classics. Proceedings of the National Academy of Sciences of the United States of America, October 1978, Volume 75, Number 10: Human milk stimulates DNA synthesis and cellular proliferation in cultured fibroblasts. By Michael Klagsbrun. Nutr Rev. 1988 Jan;46(1):21-3. — View Citation

McElhinney DB, Hedrick HL, Bush DM, Pereira GR, Stafford PW, Gaynor JW, Spray TL, Wernovsky G. Necrotizing enterocolitis in neonates with congenital heart disease: risk factors and outcomes. Pediatrics. 2000 Nov;106(5):1080-7. — View Citation

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Tanaka S, Kobayashi T, Songjinda P, Tateyama A, Tsubouchi M, Kiyohara C, Shirakawa T, Sonomoto K, Nakayama J. Influence of antibiotic exposure in the early postnatal period on the development of intestinal microbiota. FEMS Immunol Med Microbiol. 2009 Jun;56(1):80-7. doi: 10.1111/j.1574-695X.2009.00553.x. Epub 2009 Apr 6. — View Citation

Taylor SN, Basile LA, Ebeling M, Wagner CL. Intestinal permeability in preterm infants by feeding type: mother's milk versus formula. Breastfeed Med. 2009 Mar;4(1):11-5. doi: 10.1089/bfm.2008.0114. — View Citation

van Elburg RM, Fetter WP, Bunkers CM, Heymans HS. Intestinal permeability in relation to birth weight and gestational and postnatal age. Arch Dis Child Fetal Neonatal Ed. 2003 Jan;88(1):F52-5. — View Citation

Walker WA. Role of nutrients and bacterial colonization in the development of intestinal host defense. J Pediatr Gastroenterol Nutr. 2000;30 Suppl 2:S2-7. Review. — View Citation

Walker WA. The dynamic effects of breastfeeding on intestinal development and host defense. Adv Exp Med Biol. 2004;554:155-70. Review. — View Citation

Walsh MC, Kliegman RM. Necrotizing enterocolitis: treatment based on staging criteria. Pediatr Clin North Am. 1986 Feb;33(1):179-201. Review. — View Citation

Weaver LT, Laker MF, Nelson R, Lucas A. Milk feeding and changes in intestinal permeability and morphology in the newborn. J Pediatr Gastroenterol Nutr. 1987 May-Jun;6(3):351-8. — View Citation

Weaver LT, Laker MF, Nelson R. Intestinal permeability in the newborn. Arch Dis Child. 1984 Mar;59(3):236-41. — View Citation

Willis L, Thureen P, Kaufman J, Wymore E, Skillman H, da Cruz E. Enteral feeding in prostaglandin-dependent neonates: is it a safe practice? J Pediatr. 2008 Dec;153(6):867-9. doi: 10.1016/j.jpeds.2008.04.074. — View Citation

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* Note: There are 40 references in allClick here to view all references

Outcome

Type Measure Description Time frame Safety issue
Primary Change in urine lactulose/mannitol ratio over time Specific Aim 1: compare decrease in intestinal permeability by urine lactulose: mannitol ratios of the trophic breastmilk fed group (intervention) vs. NPO (nothing by mouth) group (current care) amongst neonates with complex CHD over 3 different time points (postnatal day 3-4, post-operative day 7-8, and post-operative day 13-14). post-natal day 3-4 (baseline), post-op days 7 and 14 No
Secondary Enteral Feeds Specific Aim 2: To compare the duration (in days) until goal enteral feeds are successfully achieved in the trophic breastmilk fed group vs. NPO group.
H1: Infants who receive trophic breastmilk feeds in the pre-operative period will successfully achieve goal enteral feeds in a shorter duration of time compared to those infants who were strictly NPO in the pre-operative period.
Duration (in days) until goal enteral feeds are achieved, an expected average of 3 weeks No
Secondary Intestinal Microflora Pattern Specific Aim 3: To qualitatively compare the intestinal microflora pattern over the first postpartum month as determined by stool microbiota of the trophic breastmilk fed group vs. NPO group.
H1: The microbiota patterns of those infants who receive trophic breastmilk feeds in the pre-operative period will differ from those infants who were strictly NPO in the pre-operative period.
30 days 1st post-partum month No
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