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Dini G, Ceccarelli S, Celi F. Strategies for the prevention of bronchopulmonary dysplasia. Front Pediatr 2024; 12:1439265. [PMID: 39114855 PMCID: PMC11303306 DOI: 10.3389/fped.2024.1439265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2024] [Accepted: 07/16/2024] [Indexed: 08/10/2024] Open
Abstract
Bronchopulmonary dysplasia (BPD) is a common morbidity affecting preterm infants and is associated with substantial long-term disabilities. The pathogenesis of BPD is multifactorial, and the clinical phenotype is variable. Extensive research has improved the current understanding of the factors contributing to BPD pathogenesis. However, effectively preventing and managing BPD remains a challenge. This review aims to provide an overview of the current evidence regarding the prevention of BPD in preterm infants, offering practical insights for clinicians.
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Affiliation(s)
- Gianluca Dini
- Neonatal Intensive Care Unit, Santa Maria Hospital, Terni, Italy
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Pharmacokinetics of Myo-Inositol in a Wistar Rat Animal Model. Int J Mol Sci 2022; 23:ijms231911246. [PMID: 36232547 PMCID: PMC9570207 DOI: 10.3390/ijms231911246] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 09/20/2022] [Accepted: 09/22/2022] [Indexed: 11/17/2022] Open
Abstract
Myo-inositol is the most popular inositol in living organisms, where it is present as a sugar alcohol, in a free form, and can also be described as a lipid. The aim of this study was to check the concentration change of a myo-inositol solution from the time of oral administration and over a 48 h period in Wistar-type rats. All rats received 2 g/kg of inositol as a solution in distilled water by oral gavage. Estimated parameters were based on the serum concentration of myo-inositol observed in nine individual rats with regard to time. Observations were described as a one-compartment pharmacokinetic model with first-order absorption and zero-order endogenous input of checked inositol. The highest myo-inositol concentration was observed in the first hour after oral administration in the serum of all tested rats. Then, the concentration began decreasing immediately after the maximal peak. The inositol concentration continued to decrease, but after 24 h its level was still higher than before the administration. The plasma profile of the myo-inositol concentration showed a rapid decline over time, possibly due to the metabolism of this compound.
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Sakaria RP, Dhanireddy R. Pharmacotherapy in Bronchopulmonary Dysplasia: What Is the Evidence? Front Pediatr 2022; 10:820259. [PMID: 35356441 PMCID: PMC8959440 DOI: 10.3389/fped.2022.820259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 01/26/2022] [Indexed: 11/13/2022] Open
Abstract
Bronchopulmonary Dysplasia (BPD) is a multifactorial disease affecting over 35% of extremely preterm infants born each year. Despite the advances made in understanding the pathogenesis of this disease over the last five decades, BPD remains one of the major causes of morbidity and mortality in this population, and the incidence of the disease increases with decreasing gestational age. As inflammation is one of the key drivers in the pathogenesis, it has been targeted by majority of pharmacological and non-pharmacological methods to prevent BPD. Most extremely premature infants receive a myriad of medications during their stay in the neonatal intensive care unit in an effort to prevent or manage BPD, with corticosteroids, caffeine, and diuretics being the most commonly used medications. However, there is no consensus regarding their use and benefits in this population. This review summarizes the available literature regarding these medications and aims to provide neonatologists and neonatal providers with evidence-based recommendations.
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Affiliation(s)
- Rishika P. Sakaria
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Ramasubbareddy Dhanireddy
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, United States
- Department of Obstetrics and Gynecology, University of Tennessee Health Science Center, Memphis, TN, United States
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Pavlek LR, Rivera BK, Smith CV, Randle J, Hanlon C, Small K, Bell EF, Rysavy MA, Conroy S, Backes CH. Eligibility Criteria and Representativeness of Randomized Clinical Trials That Include Infants Born Extremely Premature: A Systematic Review. J Pediatr 2021; 235:63-74.e12. [PMID: 33894262 PMCID: PMC9348995 DOI: 10.1016/j.jpeds.2021.04.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 03/23/2021] [Accepted: 04/15/2021] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To assess the eligibility criteria and trial characteristics among contemporary (2010-2019) randomized clinical trials (RCTs) that included infants born extremely preterm (<28 weeks of gestation) and to evaluate whether eligibility criteria result in underrepresentation of high-risk subgroups (eg, infants born at <24 weeks of gestation). STUDY DESIGN PubMed and Scopus were searched January 1, 2010, to December 31, 2019, with no language restrictions. RCTs with mean or median gestational ages at birth of <28 weeks of gestation were included. The study followed the PRISMA guidelines; outcomes were registered prospectively. Data extraction was performed independently by multiple observers. Study quality was evaluated using a modified Jadad scale. RESULTS Among RCTs (n = 201), 32 552 infants were included. Study participant characteristics, interventions, and outcomes were highly variable. A total of 1603 eligibility criteria were identified; rationales were provided for 18.8% (n = 301) of criteria. Fifty-five RCTs (27.4%) included infants <24 weeks of gestation; 454 (1.4%) infants were identified as <24 weeks of gestation. CONCLUSIONS The present study identifies sources of variability across RCTs that included infants born extremely preterm and reinforces the critical need for consistent and transparent policies governing eligibility criteria.
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Affiliation(s)
- Leeann R. Pavlek
- Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children’s Hospital,Department of Pediatrics and The Ohio State University Wexner Medical Center, Columbus, OH
| | - Brian K. Rivera
- Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children’s Hospital
| | - Charles V. Smith
- Center for Integrated Brain Research, Seattle Children’s Research Institute, Seattle, WA
| | - Joanie Randle
- Ohio Perinatal Research Network at Nationwide Children’s Hospital, Columbus, OH
| | - Cory Hanlon
- Ohio Perinatal Research Network at Nationwide Children’s Hospital, Columbus, OH
| | - Kristi Small
- Ohio Perinatal Research Network at Nationwide Children’s Hospital, Columbus, OH
| | - Edward F. Bell
- Stead Family Department of Pediatrics, University of Iowa, Iowa City, IA
| | - Matthew A. Rysavy
- Stead Family Department of Pediatrics, University of Iowa, Iowa City, IA
| | - Sara Conroy
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University,Biostatistics Resource at Nationwide Children’s Hospital
| | - Carl H. Backes
- Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children’s Hospital,Department of Pediatrics and The Ohio State University Wexner Medical Center, Columbus, OH,Ohio Perinatal Research Network at Nationwide Children’s Hospital, Columbus, OH,Obstetrics and Gynecology, The Ohio State University Wexner Medical Center,The Heart Center, Nationwide Children’s Hospital, Columbus, OH
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5
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Blood myo-inositol concentrations in preterm and term infants. J Perinatol 2021; 41:247-254. [PMID: 32934363 PMCID: PMC7889639 DOI: 10.1038/s41372-020-00799-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 08/14/2020] [Accepted: 08/20/2020] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To describe relationship between cord blood (representing fetal) myo-inositol concentrations and gestational age (GA) and to determine trends of blood concentrations in enterally and parenterally fed infants from birth to 70 days of age. DESIGN/METHODS Samples were collected in 281 fed or unfed infants born in 2005 and 2006. Myo-inositol concentrations were displayed in scatter plots and analyzed with linear regression models of natural log-transformed values. RESULTS In 441 samples obtained from 281 infants, myo-inositol concentrations varied from nondetectable to 1494 μmol/L. Cord myo-inositol concentrations decreased an estimated 11.9% per week increase in GA. Postnatal myo-inositol concentrations decreased an estimated 14.3% per week increase in postmenstrual age (PMA) and were higher for enterally fed infants compared to unfed infants (51% increase for fed vs. unfed infants). CONCLUSIONS Fetal myo-inositol concentrations decreased with increasing GA. Postnatal concentrations decreased with increasing PMA and were higher among enterally fed than unfed infants.
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Laganà AS, Unfer V, Garzon S, Bizzarri M. Role of inositol to improve surfactant functions and reduce IL-6 levels: A potential adjuvant strategy for SARS-CoV-2 pneumonia? Med Hypotheses 2020; 144:110262. [PMID: 33254564 PMCID: PMC7480225 DOI: 10.1016/j.mehy.2020.110262] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Revised: 08/30/2020] [Accepted: 09/05/2020] [Indexed: 01/18/2023]
Abstract
To date, the spread of SARS-CoV-2 infection is increasing worldwide and represents a primary healthcare emergency. Although the infection can be asymptomatic, several cases develop severe pneumonia and acute respiratory distress syndrome (ARDS) characterized by high levels of pro-inflammatory cytokines, primarily interleukin (IL)-6. Based on available data, the severity of ARDS and serum levels of IL-6 are key determinants for the prognosis. In this scenario, available in vitro and in vivo data suggested that myo-inositol is able to increase the synthesis and function of the surfactant phosphatidylinositol, acting on the phosphoinositide 3-kinase (PI3K)-regulated signaling, with amelioration of both immune system and oxygenation at the bronchoalveolar level. In addition, myo-inositol has been found able to decrease the levels of IL-6 in several experimental settings, due to an effect on the inositol-requiring enzyme 1 (IRE1)-X-box-binding protein 1 (XBP1) and on the signal transducer and activator of transcription 3 (STAT3) pathways. In this scenario, treatment with myo-inositol may be able to reduce IL-6 dependent inflammatory response and improve oxygenation in patients with severe ARDS by SARS-CoV-2. In addition, the action of myo-inositol on IRE1 endonuclease activity may also inhibit the replication of SARS-CoV-2, as was reported for the respiratory syncytial virus. Since the available data are extremely limited, if this potential therapeutic approach will be considered valid in the clinical practice, the necessary future investigations should aim to identify the best dose, administration route (oral, intravenous and/or aerosol nebulization), and cluster(s) of patients which may get beneficial effects from this treatment.
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Affiliation(s)
- Antonio Simone Laganà
- Department of Obstetrics and Gynecology, "Filippo Del Ponte" Hospital, University of Insubria, Varese, Italy; The Experts Group on Inositol in Basic and Clinical Research (EGOI), Italy(1).
| | - Vittorio Unfer
- The Experts Group on Inositol in Basic and Clinical Research (EGOI), Italy(1); Systems Biology Group Lab, "La Sapienza" University, Rome, Italy
| | - Simone Garzon
- Department of Obstetrics and Gynecology, "Filippo Del Ponte" Hospital, University of Insubria, Varese, Italy
| | - Mariano Bizzarri
- The Experts Group on Inositol in Basic and Clinical Research (EGOI), Italy(1); Systems Biology Group Lab, "La Sapienza" University, Rome, Italy; Department of Experimental Medicine, "La Sapienza" University, Rome, Italy
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Howlett A, Ohlsson A, Plakkal N. Inositol in preterm infants at risk for or having respiratory distress syndrome. Cochrane Database Syst Rev 2019; 7:CD000366. [PMID: 31283839 PMCID: PMC6613728 DOI: 10.1002/14651858.cd000366.pub4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Inositol is an essential nutrient required by human cells in culture for growth and survival. Inositol promotes maturation of several components of surfactant and may play a critical role in fetal and early neonatal life. A drop in inositol levels in infants with respiratory distress syndrome (RDS) can be a sign that their illness will be severe. OBJECTIVES To assess the effectiveness and safety of supplementary inositol in preterm infants with or without respiratory distress syndrome (RDS) in reducing adverse neonatal outcomes including: death (neonatal and infant deaths), bronchopulmonary dysplasia (BPD), retinopathy of prematurity (ROP), intraventricular haemorrhage (IVH), periventricular leukomalacia (PVL), necrotizing enterocolitis (NEC) and sepsis. SEARCH METHODS We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL 2018, Issue 11), MEDLINE via PubMed (1966 to 5 November 2018), Embase (1980 to 5 November 2018), and CINAHL (1982 to 5 November 2018). We searched clinical trial databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials (RCT) and quasi-randomised trials. SELECTION CRITERIA We included all randomised controlled trials of inositol supplementation of preterm infants compared with a control group that received a placebo or no intervention. Outcomes included neonatal death, infant death, bronchopulmonary dysplasia (BPD), retinopathy of prematurity (ROP), intraventricular haemorrhage (IVH), necrotizing enterocolitis (NEC) and sepsis. DATA COLLECTION AND ANALYSIS The three review authors independently abstracted data on neonatal outcomes and resolved any disagreements through discussion and consensus. Outcomes were reported as typical risk ratio (RR), risk difference (RD) and number needed to treat for an additional beneficial outcome (NNTB) or number needed to treat for an additional harmful outcome (NNTH). We used the GRADE approach to assess the quality of evidence. MAIN RESULTS Six published randomised controlled trials were identified, with a total of 1177 infants. Study quality varied for the comparison 'Inositol supplementation to preterm infants (repeat doses in any amount and any duration of treatment) versus control' and interim analyses had occurred in several trials for the outcomes of interest. In this comparison, neonatal death was found to be significantly reduced (typical RR 0.53, 95% CI 0.31 to 0.91; typical RD -0.09, 95% CI -0.16 to -0.01; NNTB 11, 95% CI 6 to 100; 3 trials, 355 neonates). Infant deaths were not reduced (typical RR 0.89, 95% CI 0.71 to 1.13; typical RD -0.02, 95% CI -0.07 to 0.02; 5 trials, 1115 infants) (low-quality evidence). ROP stage 2 or higher or stage 3 or higher was not significantly reduced (typical RR 0.89, 95% CI 0.75 to 1.06; typical RD -0.04, 95% CI -0.10 to 0.02; 3 trials, 810 infants) (moderate-quality evidence). There were no significant findings for ROP (any stage), NEC (suspected or proven), sepsis, IVH grade greater than II (moderate-quality evidence). For the comparison 'Inositol supplementation IV initially followed by enteral administration (repeat doses of 80 mg/kg/day) in preterm infants born at less than 30 weeks' postmenstrual age (PMA) compared to placebo for preterm infants at risk for or having respiratory distress syndrome' the results from two studies of high quality were included (N = 760 neonates). Recruitment to the larger study (N = 638) was terminated because of a higher rate of deaths in the inositol group. We did not downgrade the quality of the study. The meta-analyses of the outcomes of 'Type 1 ROP or death before determination of ROP outcome using the adjudicated ROP outcome', 'Type 1 ROP including adjudicated ROP outcome', 'All-cause mortality (outcome collected through first event: death, hospital discharge, hospital transfer, or 120 days after birth)' and 'Severe IVH (grade 3 or 4)' did not show significant findings (moderate-quality evidence). There were no significant findings for the outcomes 'BPD or death by it prior to 37 weeks' postmenstrual age (outcomes collected through first event: death, hospital discharge, hospital transfer, or 120 days after birth)', 'Late onset sepsis (> 72 hours of age)', and 'Suspected or proven NEC' (high-quality evidence). AUTHORS' CONCLUSIONS Based on the evidence from randomised controlled trials to date, inositol supplementation does not result in important reductions in the rates of infant deaths, ROP stage 3 or higher, type 1 ROP, IVH grades 3 or 4, BPD, NEC, or sepsis. These conclusions are based mainly on two recent randomised controlled trials in neonates less than 30 weeks' postmenstrual age (N = 760), the most vulnerable population. Currently inositol supplementation should not be routinely instituted as part of the nutritional management of preterm infants with or without RDS. It is important that infants who have been enrolled in the trials included in this review are followed to assess any effects of inositol supplementation on long-term outcomes in childhood. We do not recommend any additional trials in neonates.
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Affiliation(s)
- Alexandra Howlett
- Alberta Children's HospitalSection of NeonatologyCalgaryABCanada
- Cummings School of Medicine, University of CalgaryDepartment of PediatricsCalgaryABCanada
| | - Arne Ohlsson
- University of TorontoDepartments of Paediatrics, Obstetrics and Gynaecology and Institute of Health Policy, Management and EvaluationTorontoCanada
| | - Nishad Plakkal
- Jawaharlal Institute of Postgraduate Medical Education and Research PuducherryDepartment of PediatricsPuducherryIndia
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Du Y, He Y, Wang YL, Zhou JG, Chen C. The efficacy and safety of inositol supplementation in preterm infants to prevent retinopathy of prematurity: a systematic review and meta-analysis. BMC Ophthalmol 2019; 19:135. [PMID: 31238915 PMCID: PMC6593579 DOI: 10.1186/s12886-019-1140-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 06/04/2019] [Indexed: 11/29/2022] Open
Abstract
Background Inositol supplementation has been linked to beneficial effects on reducing the incidence of retinopathy of prematurity (ROP); however, it’s controversial. The meta-analysis aimed to check out the efficacy and safety of inositol supplementation in preterm infants for preventing ROP. Methods We conducted searches through PubMed, EMBASE, Medline, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, ClinicalTrials.gov website and conference proceedings. Randomized controlled trials comparing inositol supplementation with placebo were included. Two independent reviewers performed screening, review, and extraction. Statistical analysis was performed using R Project. Results Six studies (1194 infants) were proved eligible. In comparison with placebo, inositol supplementation revealed no effect on the incidence of severe ROP (relative risk [RR] = 0.49, 95% confidence interval [CI], 0.18–1.32; heterogeneity, P = .02; I2 = 66%; low quality of evidence [QOE]), mortality (RR = 1.25, 95% CI, 0.82–1.90; heterogeneity, P = .07; I2 = 51%; low QOE), all stages of ROP (RR = 0.98, 95% CI, 0.87–1.11; heterogeneity, P = .41; I2 = 0%; moderate QOE) and other adverse events. Sensitivity analysis showed an increased mortality in the inositol group (RR = 1.55, 95% CI, 1.14–2.11; heterogeneity, P = .30; I2 = 18%) after removing the study Hallman 1986, and meta-regression showed a significant association between publication year and efficacy of inositol compared with placebo (β = 0.1241; 95% CI, 0.0417–0.0026; z = 2.9527; p = .0032). Conclusions Based on current evidence, inositol supplementation showed no significant effect on preventing severe ROP, and exploratory sensitivity analysis showed a trend toward an increase on mortality. Electronic supplementary material The online version of this article (10.1186/s12886-019-1140-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yang Du
- Department of Neonatology, Children's Hospital of Fudan University, 399 Wanyuan Road, Minhang District, Shanghai, 201102, China
| | - Yue He
- Department of Neonatology, Children's Hospital of Fudan University, 399 Wanyuan Road, Minhang District, Shanghai, 201102, China
| | - Yue-Lin Wang
- Department of Ophthalmology, Peking Union Medical College Hospital, Beijing, China
| | - Jian-Guo Zhou
- Department of Neonatology, Children's Hospital of Fudan University, 399 Wanyuan Road, Minhang District, Shanghai, 201102, China
| | - Chao Chen
- Department of Neonatology, Children's Hospital of Fudan University, 399 Wanyuan Road, Minhang District, Shanghai, 201102, China.
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Pirgozliev V, Brearley C, Rose S, Mansbridge S. Manipulation of plasma myo-inositol in broiler chickens: effect on growth performance, dietary energy, nutrient availability, and hepatic function. Poult Sci 2019; 98:260-268. [DOI: 10.3382/ps/pey341] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 08/20/2018] [Indexed: 01/10/2023] Open
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Phelps DL, Watterberg KL, Nolen TL, Cole CA, Cotten CM, Oh W, Poindexter BB, Zaterka-Baxter KM, Das A, Lacy CB, Scorsone AM, Walsh MC, Bell EF, Kennedy KA, Schibler K, Sokol GM, Laughon MM, Lakshminrusimha S, Truog WE, Garg M, Carlo WA, Laptook AR, Van Meurs KP, Carlton DP, Graf A, DeMauro SB, Brion LP, Shankaran S, Orge FH, Olson RJ, Mintz-Hittner H, Yang MB, Haider KM, Wallace DK, Chung M, Hug D, Tsui I, Cogen MS, Donahue JP, Gaynon M, Hutchinson AK, Bremer DL, Quinn G, He YG, Lucas WR, Winter TW, Kicklighter SD, Kumar K, Chess PR, Colaizy TT, Hibbs AM, Ambalavanan N, Harmon HM, McGowan EC, Higgins RD. Effects of Myo-inositol on Type 1 Retinopathy of Prematurity Among Preterm Infants <28 Weeks' Gestational Age: A Randomized Clinical Trial. JAMA 2018; 320:1649-1658. [PMID: 30357297 PMCID: PMC6233812 DOI: 10.1001/jama.2018.14996] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
IMPORTANCE Previous studies of myo-inositol in preterm infants with respiratory distress found reduced severity of retinopathy of prematurity (ROP) and less frequent ROP, death, and intraventricular hemorrhage. However, no large trials have tested its efficacy or safety. OBJECTIVE To test the adverse events and efficacy of myo-inositol to reduce type 1 ROP among infants younger than 28 weeks' gestational age. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial included 638 infants younger than 28 weeks' gestational age enrolled from 18 neonatal intensive care centers throughout the United States from April 17, 2014, to September 4, 2015; final date of follow-up was February 12, 2016. The planned enrollment of 1760 participants would permit detection of an absolute reduction in death or type 1 ROP of 7% with 90% power. The trial was terminated early due to a statistically significantly higher mortality rate in the myo-inositol group. INTERVENTIONS A 40-mg/kg dose of myo-inositol was given every 12 hours (initially intravenously, then enterally when feeding; n = 317) or placebo (n = 321) for up to 10 weeks. MAIN OUTCOMES AND MEASURES Type 1 ROP or death before determination of ROP outcome was designated as unfavorable. The designated favorable outcome was survival without type 1 ROP. RESULTS Among 638 infants (mean, 26 weeks' gestational age; 50% male), 632 (99%) received the trial drug or placebo and 589 (92%) had a study outcome. Death or type 1 ROP occurred more often in the myo-inositol group vs the placebo group (29% vs 21%, respectively; adjusted risk difference, 7% [95% CI, 0%-13%]; adjusted relative risk, 1.41 [95% CI, 1.08-1.83], P = .01). All-cause death before 55 weeks' postmenstrual age occurred in 18% of the myo-inositol group and in 11% of the placebo group (adjusted risk difference, 6% [95% CI, 0%-11%]; adjusted relative risk, 1.66 [95% CI, 1.14-2.43], P = .007). The most common serious adverse events up to 7 days of receiving the ending dose were necrotizing enterocolitis (6% for myo-inositol vs 4% for placebo), poor perfusion or hypotension (7% vs 4%, respectively), intraventricular hemorrhage (10% vs 9%), systemic infection (16% vs 11%), and respiratory distress (15% vs 13%). CONCLUSIONS AND RELEVANCE Among premature infants younger than 28 weeks' gestational age, treatment with myo-inositol for up to 10 weeks did not reduce the risk of type 1 ROP or death vs placebo. These findings do not support the use of myo-inositol among premature infants; however, the early termination of the trial limits definitive conclusions.
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Affiliation(s)
- Dale L. Phelps
- School of Medicine and Dentistry, University of Rochester, Rochester, New York
| | | | - Tracy L. Nolen
- Social, Statistical, and Environmental Sciences Unit, RTI International, Research Triangle Park, North Carolina
| | - Carol A. Cole
- School of Medicine and Dentistry, University of Rochester, Rochester, New York
| | | | - William Oh
- Department of Pediatrics, Women & Infants’ Hospital, Brown University, Providence, Rhode Island
| | - Brenda B. Poindexter
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
- Department of Pediatrics, School of Medicine, Indiana University, Indianapolis
| | - Kristin M. Zaterka-Baxter
- Social, Statistical, and Environmental Sciences Unit, RTI International, Research Triangle Park, North Carolina
| | - Abhik Das
- Social, Statistical, and Environmental Sciences Unit, RTI International, Rockville, Maryland
| | | | - Ann Marie Scorsone
- School of Medicine and Dentistry, University of Rochester, Rochester, New York
| | - Michele C. Walsh
- Department of Pediatrics, Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, Ohio
| | | | - Kathleen A. Kennedy
- Department of Pediatrics, McGovern Medical School, University of Texas Health Science Center, Houston
| | - Kurt Schibler
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Gregory M. Sokol
- Department of Pediatrics, School of Medicine, Indiana University, Indianapolis
| | - Matthew M. Laughon
- Division of Neonatal/Perinatal Medicine, Department of Pediatrics, University of North Carolina, Chapel Hill
| | | | - William E. Truog
- Department of Pediatrics, Children’s Mercy Hospital and University of Missouri School of Medicine, Kansas City
| | - Meena Garg
- Department of Pediatrics, University of California, Los Angeles
| | | | - Abbot R. Laptook
- Department of Pediatrics, Women & Infants’ Hospital, Brown University, Providence, Rhode Island
| | - Krisa P. Van Meurs
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, California
| | - David P. Carlton
- Department of Pediatrics, Emory University School of Medicine and Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Amanda Graf
- Department of Pediatrics, Nationwide Children’s Hospital, Columbus, Ohio
| | - Sara B. DeMauro
- Department of Pediatrics, Children’s Hospital of Philadelphia and University of Pennsylvania, Philadelphia
| | - Luc P. Brion
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas
| | - Seetha Shankaran
- Department of Pediatrics, Wayne State University, Detroit, Michigan
| | - Faruk H. Orge
- Department of Ophthalmology, Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, Ohio
| | - Richard J. Olson
- Department of Ophthalmology and Visual Sciences, University of Iowa, Iowa City
| | - Helen Mintz-Hittner
- Department of Ophthalmology and Visual Science, McGovern Medical School, University of Texas Health Science Center, Houston
| | - Michael B. Yang
- Department of Ophthalmology, Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Kathryn M. Haider
- Department of Ophthalmology, School of Medicine, Indiana University, Indianapolis
| | - David K. Wallace
- Department of Pediatrics, Duke University, Durham, North Carolina
| | - Mina Chung
- Department of Ophthalmology, School of Medicine and Dentistry, University of Rochester, Rochester, New York
| | - Denise Hug
- Department of Ophthalmology, Children’s Mercy Hospital and University of Missouri School of Medicine, Kansas City
| | - Irena Tsui
- Department of Ophthalmology, University of California, Los Angeles
| | - Martin S. Cogen
- Department of Ophthalmology, University of Alabama at Birmingham
| | - John P. Donahue
- Alpert Medical School, Women & Infants’ Hospital, Brown University, Providence, Rhode Island
| | - Michael Gaynon
- Department of Ophthalmology, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, California
| | - Amy K. Hutchinson
- Department of Ophthalmology, Emory University School of Medicine and Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Don L. Bremer
- Department of Ophthalmology, Nationwide Children’s Hospital, Columbus, Ohio
| | - Graham Quinn
- Department of Ophthalmology, Children’s Hospital of Philadelphia and University of Pennsylvania, Philadelphia
| | - Yu-Guang He
- Department of Ophthalmology, University of Texas Southwestern Medical Center, Dallas
| | - William R. Lucas
- Department of Ophthalmology, Wayne State University, Detroit, Michigan
| | - Timothy W. Winter
- Division of Ophthalmology, Department of Surgery, Health Sciences Center, University of New Mexico, Albuquerque
| | - Stephen D. Kicklighter
- Department of Pediatrics, Division of Neonatology, WakeMed Health and Hospitals, Raleigh, North Carolina
| | - Kartik Kumar
- Department of Pediatrics, McGovern Medical School, University of Texas Health Science Center, Houston
| | - Patricia R. Chess
- School of Medicine and Dentistry, University of Rochester, Rochester, New York
| | | | - Anna Marie Hibbs
- Department of Pediatrics, Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, Ohio
| | | | - Heidi M. Harmon
- Department of Pediatrics, School of Medicine, Indiana University, Indianapolis
| | - Elisabeth C. McGowan
- Department of Pediatrics, Women & Infants’ Hospital, Brown University, Providence, Rhode Island
| | - Rosemary D. Higgins
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
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11
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Koschnitzky JE, Keep RF, Limbrick DD, McAllister JP, Morris JA, Strahle J, Yung YC. Opportunities in posthemorrhagic hydrocephalus research: outcomes of the Hydrocephalus Association Posthemorrhagic Hydrocephalus Workshop. Fluids Barriers CNS 2018; 15:11. [PMID: 29587767 PMCID: PMC5870202 DOI: 10.1186/s12987-018-0096-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 03/09/2018] [Indexed: 12/19/2022] Open
Abstract
The Hydrocephalus Association Posthemorrhagic Hydrocephalus Workshop was held on July 25 and 26, 2016 at the National Institutes of Health. The workshop brought together a diverse group of researchers including pediatric neurosurgeons, neurologists, and neuropsychologists with scientists in the fields of brain injury and development, cerebrospinal and interstitial fluid dynamics, and the blood-brain and blood-CSF barriers. The goals of the workshop were to identify areas of opportunity in posthemorrhagic hydrocephalus research and encourage scientific collaboration across a diverse set of fields. This report details the major themes discussed during the workshop and research opportunities identified for posthemorrhagic hydrocephalus. The primary areas include (1) preventing intraventricular hemorrhage, (2) stopping primary and secondary brain damage, (3) preventing hydrocephalus, (4) repairing brain damage, and (5) improving neurodevelopment outcomes in posthemorrhagic hydrocephalus.
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Affiliation(s)
| | - Richard F. Keep
- University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI 48109 USA
| | - David D. Limbrick
- Washington University in St. Louis School of Medicine, 660 S. Euclid Ave, St. Louis, MO 63110 USA
| | - James P. McAllister
- Washington University in St. Louis School of Medicine, 660 S. Euclid Ave, St. Louis, MO 63110 USA
| | - Jill A. Morris
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Neuroscience Center, 6001 Executive Blvd, NSC Rm 2112, Bethesda, MD 20892 USA
| | - Jennifer Strahle
- Washington University in St. Louis School of Medicine, 660 S. Euclid Ave, St. Louis, MO 63110 USA
| | - Yun C. Yung
- Sanford Burnham Prebys Medical Discovery Institute, 10901 North Torrey Pines Rd., Building 7, La Jolla, CA 92037 USA
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12
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Ling R, Greenough A. Advances in emerging treatment options to prevent bronchopulmonary dysplasia. Expert Opin Orphan Drugs 2017. [DOI: 10.1080/21678707.2017.1281736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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13
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Das A, Tyson J, Pedroza C, Schmidt B, Gantz M, Wallace D, Truog WE, Higgins RD. Methodological issues in the design and analyses of neonatal research studies: Experience of the NICHD Neonatal Research Network. Semin Perinatol 2016; 40:374-384. [PMID: 27344192 PMCID: PMC5065743 DOI: 10.1053/j.semperi.2016.05.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Impressive advances in neonatology have occurred over the 30 years of life of The Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network (NRN). However, substantial room for improvement remains in investigating and further developing the evidence base for improving outcomes among the extremely premature. We discuss some of the specific methodological challenges in the statistical design and analysis of randomized trials and observational studies in this population. Challenges faced by the NRN include designing trials for unusual or rare outcomes, accounting for and explaining center variations, identifying other subgroup differences, and balancing safety and efficacy concerns between short-term hospital outcomes and longer-term neurodevelopmental outcomes. In conclusion, the constellation of unique patient characteristics in neonates calls for broad understanding and careful consideration of the issues identified in this article for conducting rigorous studies in this population.
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Affiliation(s)
- Abhik Das
- Biostatistics and Epidemiology Division, RTI International, 6110 Executive Blvd, Suite 902, Rockville, MD 20852.
| | - Jon Tyson
- University of Texas Health Science Center at Houston, Houston, TX
| | - Claudia Pedroza
- University of Texas Health Science Center at Houston, Houston, TX
| | - Barbara Schmidt
- Department of Pediatrics, University of Pennsylvania, Philadelphia, PA
| | - Marie Gantz
- Biostatistics and Epidemiology Division, RTI International, Research Triangle Park, NC
| | - Dennis Wallace
- Biostatistics and Epidemiology Division, RTI International, Research Triangle Park, NC
| | - William E. Truog
- Children’s Mercy Hospitals and Clinics and the University of Missouri-Kansas City School of Medicine, Kansas City, MO
| | - Rosemary D. Higgins
- Eunice Kennedy Shriver National Institute of Health & Human Development, National Institutes of Health, Bethesda, MD
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14
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Phelps DL, Ward RM, Williams RL, Nolen TL, Watterberg KL, Oh W, Goedecke M, Ehrenkranz RA, Fennell T, Poindexter BB, Cotten CM, Hallman M, Frantz ID, Faix RG, Zaterka-Baxter KM, Das A, Ball MB, Lacy CB, Walsh MC, Carlo WA, Sánchez PJ, Bell EF, Shankaran S, Carlton DP, Chess PR, Higgins RD. Safety and pharmacokinetics of multiple dose myo-inositol in preterm infants. Pediatr Res 2016; 80:209-17. [PMID: 27074126 PMCID: PMC5198845 DOI: 10.1038/pr.2016.97] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2015] [Accepted: 03/03/2016] [Indexed: 01/13/2023]
Abstract
BACKGROUND Preterm infants with respiratory distress syndrome (RDS) given inositol had reduced bronchopulmonary dysplasia (BPD), death and severe retinopathy of prematurity (ROP). We assessed the safety and pharmacokinetics of daily inositol to select a dose providing serum levels previously associated with benefit, and to learn if accumulation occurred when administered throughout the normal period of retinal vascularization. METHODS Infants ≤ 29 wk GA (n = 122, 14 centers) were randomized and treated with placebo or inositol at 10, 40, or 80 mg/kg/d. Intravenous administration converted to enteral when feedings were established, and continued to the first of 10 wk, 34 wk postmenstrual age (PMA) or discharge. Serum collection employed a sparse sampling population pharmacokinetics design. Inositol urine losses and feeding intakes were measured. Safety was prospectively monitored. RESULTS At 80 mg/kg/d mean serum levels reached 140 mg/l, similar to Hallman's findings. Levels declined after 2 wk, converging in all groups by 6 wk. Analyses showed a mean volume of distribution 0.657 l/kg, clearance 0.058 l/kg/h, and half-life 7.90 h. Adverse events and comorbidities were fewer in the inositol groups, but not significantly so. CONCLUSION Multiple dose inositol at 80 mg/kg/d was not associated with increased adverse events, achieves previously effective serum levels, and is appropriate for investigation in a phase III trial.
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Affiliation(s)
- Dale L. Phelps
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Robert M. Ward
- Department of Pediatrics, and Pediatric Pharmacology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Rick L. Williams
- Social, Statistical and Environmental Sciences Unit, RTI International, Research Triangle Park, NC, USA
| | - Tracy L. Nolen
- Social, Statistical and Environmental Sciences Unit, RTI International, Research Triangle Park, NC, USA
| | - Kristi L. Watterberg
- Department of Pediatrics, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - William Oh
- Department of Pediatrics, Women & Infants’ Hospital Brown University, Providence, RI, USA
| | - Michael Goedecke
- Social, Statistical and Environmental Sciences Unit, RTI International, Research Triangle Park, NC, USA
| | | | - Timothy Fennell
- Pharmacology and Toxicology Division, RTI International, Research Triangle Park, NC, USA
| | - Brenda B. Poindexter
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | | | - Mikko Hallman
- PEDEGO Research Center, and MRC Oulu, and Oulu University Hospital, Oulu, Finland
| | - Ivan D. Frantz
- Department of Pediatrics, Floating Hospital for Children, Tufts Medical Center, Boston, MA, USA
| | - Roger G. Faix
- Department of Pediatrics, and Pediatric Pharmacology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Kristin M. Zaterka-Baxter
- Social, Statistical and Environmental Sciences Unit, RTI International, Research Triangle Park, NC, USA
| | - Abhik Das
- Social, Statistical and Environmental Sciences Unit, RTI International, Rockville, MD, USA
| | - M. Bethany Ball
- Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, CA, USA
| | - Conra Backstrom Lacy
- Department of Pediatrics, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Michele C. Walsh
- Department of Pediatrics, Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, OH, USA
| | - Waldemar A. Carlo
- Division of Neonatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Pablo J. Sánchez
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Edward F. Bell
- Department of Pediatrics, University of Iowa, Iowa City, IA, USA
| | - Seetha Shankaran
- Department of Pediatrics, Wayne State University, Detroit, MI, USA
| | - David P. Carlton
- Department of Pediatrics, Emory University School of Medicine and Children’s Healthcare of Atlanta, Atlanta, GA, USA
| | - Patricia R. Chess
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Rosemary D. Higgins
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
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15
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Abstract
Inositol is a 6-carbon sugar alcohol that has been shown in limited studies to reduce retinopathy of prematurity and chronic lung disease in premature newborns. Developmentally it has a high concentration in the fetus that decreases with gestational age. It is transported from the fetus to the mother across the placenta. Although studies are underway to determine inositol kinetics in premature newborns treated therapeutically, the effects of gestational age, age after birth, and feeding on inositol concentrations after birth have not been studied adequately in premature newborns. Such studies would minimize blood removal and trauma in preterm newborns by using plasma samples scavenged from the clinical laboratory to measure inositol after birth, if they remain stable. This report describes a new high pressure liquid chromatographic assay for inositol and its use to study the stability of inositol in conditions of storage that might be encountered within the clinical laboratory. The assay is linear from 0 to 1000 Mm with a lower limit of quantitation of 50 μM. Inositol in human plasma remains stable in refrigeration and at room temperature for up to 14 days and is not affected by storage in red blood cells that are intact or lysed. Anticoagulants encountered in clinical blood samples do not interfere with the chromatograms. Thus, it is feasible to measure the changes in inositol concentrations in plasma from preterm newborns that is scavenged from the clinical laboratory after storage for as long as 14 days.
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Affiliation(s)
- Robert M Ward
- Divisions of Neonatology and Pediatric Pharmacology, Adjunct Professor, Pharmacology/Toxicology, University of Utah, 295 Chipeta Way, Salt Lake City, UT 84108, USA
| | - John Sweeley
- Department of Pediatrics, University of Utah, 417 Wakara Way, Salt Lake City, UT 84108, USA
| | - Ralph A Lugo
- Department of Pharmacy Practice, Gatton College of Pharmacy, East Tennessee State University, Johnson City, Tennessee 37614, USA
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16
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Darlow BA. Retinopathy of prematurity: New developments bring concern and hope. J Paediatr Child Health 2015; 51:765-70. [PMID: 25757043 DOI: 10.1111/jpc.12860] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/20/2015] [Indexed: 12/22/2022]
Abstract
Blindness from retinopathy of prematurity (ROP) in Australian and New Zealand is an uncommon event although 3% of <31 weeks gestation infants receive treatment for the disease. New world-wide estimates of the incidence of blindness from ROP are much higher than previously at 20 000 children annually. The impact of severe ROP can be reduced through good evidence-based care of very preterm infants and careful organisation of eye examinations and follow-up services. Recent oxygen saturation targeting trial results might mean the adoption of higher targets than formerly in very preterm infants and will require vigilance to ensure all eligible infants are examined appropriately. A true screening examination for acute ROP might involve non-opthalmologists obtaining photographic retinal images and remote reading of these. Although treatment with laser gives good outcomes, there is interest in intravitreal anti-vascular endothelial factor agents, but issues concerning the systemic safety and retinal results of such treatment are unresolved.
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Affiliation(s)
- Brian A Darlow
- Department of Paediatrics, University of Otago at Christchurch, Christchurch, New Zealand
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17
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Schimpf KJ, Meek CC, Leff RD, Phelps DL, Schmitz DJ, Cordle CT. Quantification of myo-inositol, 1,5-anhydro- D-sorbitol, and D-chiro-inositol using high-performance liquid chromatography with electrochemical detection in very small volume clinical samples. Biomed Chromatogr 2015; 29:1629-36. [PMID: 26010453 DOI: 10.1002/bmc.3470] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Revised: 02/05/2015] [Accepted: 03/02/2015] [Indexed: 11/11/2022]
Abstract
Inositol is a six-carbon sugar alcohol and is one of nine biologically significant isomers of hexahydroxycyclohexane. Myo-inositol is the primary biologically active form and is present in higher concentrations in the fetus and newborn than in adults. It is currently being examined for the prevention of retinopathy of prematurity in newborn preterm infants. A robust method for quantifying myo-inositol (MI), D-chiro-inositol (DCI) and 1,5-anhydro- D-sorbitol (ADS) in very small-volume (25 μL) urine, blood serum and/or plasma samples was developed. Using a multiple-column, multiple mobile phase liquid chromatographic system with electrochemical detection, the method was validated with respect to (a) selectivity, (b) accuracy/recovery, (c) precision/reproducibility, (d) sensitivity, (e) stability and (f) ruggedness. The standard curve was linear and ranged from 0.5 to 30 mg/L for each of the three analytes. Above-mentioned performance measures were within acceptable limits described in the Food and Drug Administration's Guidance for Industry: Bioanalytical Method Validation. The method was validated using blood serum and plasma collected using four common anticoagulants, and also by quantifying the accuracy and sensitivity of MI measured in simulated urine samples recovered from preterm infant diaper systems. The method performs satisfactorily measuring the three most common inositol isomers on 25 μL clinical samples of serum, plasma, milk, and/or urine. Similar performance is seen testing larger volume samples of infant formulas and infant formula ingredients. MI, ADS and DCI may be accurately tested in urine samples collected from five different preterm infant diapers if the urine volume is greater than 2-5 mL.
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Affiliation(s)
- Karen J Schimpf
- Abbott Nutrition, 3300 Stelzer Road, Columbus, OH, 34219, USA
| | - Claudia C Meek
- School of Pharmacy, Texas Tech University Health Sciences Center, 5920 Forest Park Road - Suite 400, Dallas, TX, 75235, USA
| | - Richard D Leff
- School of Pharmacy, Texas Tech University Health Sciences Center, 5920 Forest Park Road - Suite 400, Dallas, TX, 75235, USA
| | - Dale L Phelps
- University of Rochester School of Medicine and Dentistry, 601 Elmwood Ave, Pediatrics, Box 651, Rochester, NY, 14642, USA
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18
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Howlett A, Ohlsson A, Plakkal N. Inositol in preterm infants at risk for or having respiratory distress syndrome. Cochrane Database Syst Rev 2015:CD000366. [PMID: 25927089 DOI: 10.1002/14651858.cd000366.pub3] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Inositol is an essential nutrient required by human cells in culture for growth and survival. Inositol promotes maturation of several components of surfactant and may play a critical role in fetal and early neonatal life. OBJECTIVES To assess the effectiveness and safety of supplementary inositol in preterm infants with or without respiratory distress syndrome (RDS) in reducing adverse neonatal outcomes. SEARCH METHODS The Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, CINAHL, Clinicaltrials.gov and Controlled-trials.com were searched in September 2014. The reference lists of identified randomised controlled trials (RCTs), personal files and Web of Science were searched. SELECTION CRITERIA All RCTs of inositol supplementation of preterm infants compared with a control group that received a placebo or no intervention were included. Outcomes of interest were neonatal death, infant death, bronchopulmonary dysplasia (BPD), retinopathy of prematurity (ROP), intraventricular haemorrhage (IVH), necrotizing enterocolitis (NEC) and sepsis. DATA COLLECTION AND ANALYSIS Data on neonatal outcomes were abstracted independently by the three review authors and any discrepancy was resolved through consensus. Outcomes were reported as relative risk (RR), risk difference (RD) and number needed to treat to benefit (NNTB) or to harm (NNTH). MAIN RESULTS Four published RCTs and one ongoing RCT were identified. Study quality varied and interim analyses had occurred in all trials of repeat doses of inositol that provided data for the outcomes of interest in this review. In these trials neonatal death was found to be significantly reduced (3 trials, 355 neonates; typical RR 0.53, 95% CI 0.31 to 0.91; typical RD -0.09, 95% CI -0.17 to -0.03; NNTB 11, 95% CI 6 to 33). Infant deaths were reduced (3 trials, 355 infants; typical RR 0.55, 95% CI 0.40 to 0.77; typical RD -0.18, 95% CI -0.27 to -0.08; NNTB 6, 95% CI 4 to 13). ROP stage ≥ 3 was significantly reduced (2 trials, 262 infants; typical RR 0.09, 95% CI 0.01 to 0.67; typical RD -0.08, 95% CI -0.13 to -0.03; NNTB 13, 95% CI 8 to 33) and IVH grade > II was significantly decreased (3 trials, 355 infants; typical RR 0.53, 95% CI 0.31 to 0.90; typical RD -0.09, 95% CI -0.16 to -0.02; NNTB 11, 95% CI 6 to 50). Neither sepsis nor NEC differed significantly between groups. One study (74 infants) that administered a single dose of inositol (60 or 120 mg/kg) found no significant differences in adverse outcomes using RR, but an increased RD for BPD at 36 weeks postmenstrual age (RD 0.23, 95% CI 0.03 to 0.43; NNTH 4, 95% CI 2 to 33). This result should be interpreted with caution as only one dose of inositol was given and only the RD, but not the RR, was significant. One ongoing large study of repeat doses of inositol in preterm infants was identified. AUTHORS' CONCLUSIONS Inositol supplementation results in statistically significant and clinically important reductions in important short-term adverse neonatal outcomes. A large size multi-centre randomised controlled trial is currently ongoing and the trial will likely confirm or refute the findings from this systematic review.
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Affiliation(s)
- Alexandra Howlett
- Section of Neonatology, Alberta Children's Hospital, Calgary, AB, Canada
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19
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Beam KS, Aliaga S, Ahlfeld SK, Cohen-Wolkowiez M, Smith PB, Laughon MM. A systematic review of randomized controlled trials for the prevention of bronchopulmonary dysplasia in infants. J Perinatol 2014; 34:705-10. [PMID: 25010224 PMCID: PMC4152555 DOI: 10.1038/jp.2014.126] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Revised: 03/25/2014] [Accepted: 05/05/2014] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Bronchopulmonary dysplasia (BPD) is the most common cause of pulmonary morbidity in premature infants and is associated with life-long morbidities. Developing drugs for the prevention of BPD would improve public health. We sought to determine characteristics of favorable randomized controlled trials (RCTs) of drugs for BPD prevention. STUDY DESIGN We searched MEDLINE and EMBASE from 1992 to 2014 using the MeSH terms 'BPD' and 'respiratory distress syndrome, newborn'. We included a Cochrane Library search to ensure inclusion of all available RCTs. We identified RCTs with BPD as a primary or secondary outcome and determined the definition of BPD used by the study. We determined whether a phase I or phase II study-to determine drug safety, efficacy or optimal dose-was performed before the RCT. Finally, we searched the Cochrane Library for meta-analyses for each drug and used the results of available meta-analyses to define a favorable versus unfavorable RCT. RESULT We identified 2026 articles; 47 RCTs met our inclusion criteria encompassing 21 drugs; 5 of the drugs reduced the incidence of BPD. We found data from phase I or II studies for 16 of the drugs, but only 1 demonstrated a reduction of BPD. CONCLUSION The majority of the drugs studied in RCTs failed to reduce the incidence of BPD. Performing early-phase studies before phase III trials might provide necessary information on drugs and drug doses capable of preventing BPD, thus informing the development of future RCTs.
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Affiliation(s)
| | - Sofia Aliaga
- University of North Carolina, Chapel Hill, NC, USA
| | | | | | | | - Matthew M. Laughon
- University of North Carolina, Chapel Hill, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
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