A Multi-center, Double-blind, Randomized, Three-Arm, Parallel-Group, Placebo Controlled Study to Assess the Efficacy and Safety of NTRA-2112 on Intestinal Malabsorption in Preterm Infants
Phase: PHASE3
Conditions: Premature Birth of Newborn, Intestinal Malabsorption
Sponsor: Elgan Pharma Ltd.

                    NCT02510560
Clinical Trial Protocol: FIT-04 
Study Title: 
Protocol Number: 
Protocol Version 
Protocol Date: 
EudraCT Number 
Sponsor: 
; 
Nutrinia 
Version 7 dated 10 May 2017 
A Multi-center, Double-blind, Randomized, Three-Arm, 
Parallel-Group, Placebo Controlled Study to Assess the 
Efficacy and Safety of NTRA-2112 on Intestinal 
Malabsorption in Preterm Infants 
FIT-04 
7 
10 May 2017 
2014-002624-28 
Nutrinia Ltd 
6 Ha-Khilazon Street 
Ramat-Gan, 5252270 
Israel 
CONFIDENTIAL 
This document is a confidential communication of Nutrinia Ltd. Acceptance of t his document constit utes 
agreement by t he recipient t hat no unpublished information contained herein will be published or 
disclosed without prior written approval, with the except ion of disclosure to t he appropriate Inst itutional 
Review Board/Independent Ethics Committee and/or Regulatory Authority under t he condition that 
confidentiality is maintained 
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PROTOCOL SIGNATURE PAGE 
Protocol Number: FIT-04 Protocol 
--
-
STATEMENT OF COMPLIANCE 
This clinical trial w ill be conducted in compliance with the protocol, International Conference on 
Harmonization Good Clinical Practice Guidelines E6 {ICH-GCP) and the applicable regulatory requirements. 
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Clinical Trial Protocol: FIT-04 
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INVESTIGATOR SIGNATURE PAGE 
Protocol Title: A Multi-center, Double-blind, Randomized, Three-Arm, Parallel group, Placebo 
Controlled Study to Assess the Efficacy and Safety of NTRA-2112 on Intestinal Malabsorption in Preterm 
Infants 
I have read and understood the protocol and agree to implement the study in accordance with the 
procedures set forth in the protocol and in accordance w ith the Sponsor's guidelines, all applicable 
government regulations and the International Conference on Harmonization Good Clinical Practice 
Guidelines E6 (ICH-GCP). 
I will provide adequate protocol training to my associates, colleagues and employees assisting in the 
conduct of the study. 
I will obtain Institutional Review Board (IRB)/lndependent Ethics Committee (IEC) approval of the protocol 
and the subject Informed Consent Form prior to enrollment of subjects in the study. I understand that any 
modifications to the protocol made during the course of the study must first be approved by the IRB/ IEC 
except w hen such modification is made to remove an immediate hazard to a subject. 
I w ill ensure that a fully executed subject Informed Consent Form is obtained on behalf of each subject prior 
to initiation of any study procedures. 
I will promptly report (within 24 hours for any related SAEs and any SAE resulted in death, and within 48 
hours for unrelated SAEs other than death) any Serious Adverse Event that occurs during the course of the 
study in accordance with the procedures described in Section 11 of the protocol. 
I will allow the Sponsor, Nutrinia Ltd. and its agents, as w ell as the United States (US) Food and Drug 
Administration (FDA) and other regulatory agencies, to inspect study facilities and pertinent records at 
reasonable times and in a reasonable manner, ensuring subjects confidentiality. If I am notified that this 
study is to be inspected by a regulatory agency, I will notify the Sponsor as soon as possible thereafter (no 
later than w ithin one w eek after notification). 
Investigator's name 
Investigator's Signature 
Date 
Site Name: 
Site Address: 
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TABLE OF CONTENTS 
1. 
2. 
3. 
4. 
5. 
6. 
7. 
8. 
9. 
KEY TRIAL CONTACTS ......................................................................................................................... 8 
SYNOPSIS ........................................................................................................................................... 9 
DEFINITIONS .................................................................................................................................... 14 
ABBREVIATIONS ............................................................................................................................... 15 
BACKGROUND AND RATIONALE ...................................................................................................... 17 
5.1. 
General Introduction ............................................................................................................... 17 
5.2. 
Rationale and Justification for the Study ................................................................................ 19 
STUDY OBJECTIVES .......................................................................................................................... 21 
6.1. 
Primary Objective .................................................................................................................... 21 
6.2. 
Secondary Objectives .............................................................................................................. 21 
6.3. 
Safety Objective ....................................................................................................................... 22 
STUDY DESIGN ................................................................................................................................. 22 
STUDY POPULATION ........................................................................................................................ 22 
8.1. 
Study Participants .................................................................................................................... 22 
8.2. 
Inclusion Criteria ...................................................................................................................... 23 
8.3. 
Exclusion Criteria ..................................................................................................................... 23 
STUDY PROCEDURES ....................................................................................................................... 24 
9.1. 
Screening and Eligibility Assessment ....................................................................................... 24 
9.2. 
Randomization, Blinding and Code-breaking .......................................................................... 25 
9.3. 
Treatment Period (Day 1-28 or discharge from hospital) ....................................................... 25 
9.3.1. 
Treatment period - Day 1 to Day 27 ........................................................................................ 26 
9.3.2. 
Last day of treatment Day 28 or Day of Discharge if Achieved Before Day 28 ....................... 27 
9.3.2.1. 
Discharge to a Secondary Site ................................................................................................. 27 
9.3.3. 
Discharge if After Day 28 ......................................................................................................... 28 
9.4. 
Follow-up visits ........................................................................................................................ 28 
9.4.1. 
3 Months Corrected Age Follow-up Visit (±14 days) ............................................................... 28 
9.4.2. 12 Months Corrected Age Follow-up Visit (±30 days) 
............................................................. 29 
9.4.3. 
Last study visit - 24 Months Corrected Age Follow-up Visit (±30 days) .................................. 29 
9.5. 
Discontinuation/Withdrawal of Infants ................................................................................... 34 
9.5.1. 
Discontinuation Criteria ........................................................................................................... 34 
9.5.2. 
Premature Study Termination ................................................................................................. 35 
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10. 
INVESTIGATIONAL MEDICINAL PRODUCT (IMP) ............................................................................. 36 
10.1. 
IMP Description ....................................................................................................................... 36 
10.2. 
Presentation and Storage Conditions ...................................................................................... 37 
10.3. 
Method of Administration ....................................................................................................... 37 
10.4. 
Concomitant Therapy, Restrictions and Rescue Treatment .................................................... 37 
10.5. 
Treatment Compliance ............................................................................................................ 37 
10.6. 
Packaging and Labelling ........................................................................................................... 37 
10. 7. 
Storage of Study Medication ................................................................................................... 38 
10.8. 
Accountability of the Study Medication .................................................................................. 38 
11. 
SAFETY MEASURMENTS .................................................................................................................. 38 
11.1. 
Definitions ............................................................................................................................... 39 
11.2. 
Causality .................................................................................................................................. 39 
11.3. 
Collecting, Recording and Reporting of Adverse Events and Serious Adverse Events ............ 40 
11.4. 
Safety Monitoring Plan ............................................................................................................ 42 
11.5. 
Reporting of SUSARs ................................................................................................................ 43 
12. 
SAMPLE SIZE AND STATISTICAL METHODS ...................................................................................... 43 
12.1. 
Overview .................................................................................................................................. 43 
12.1.1. 
Design Considerations ............................................................................................................. 43 
12.2. 
Analysis Sets ............................................................................................................................ 45 
12.2.1. 
Safety Analysis Set ................................................................................................................... 45 
12.2.2. 
Full Analysis Set (Intention-to-treat) ....................................................................................... 45 
12.2.3. 
Per-Protocol Analysis Sets ....................................................................................................... 45 
12.2.4. 
Safety ....................................................................................................................................... 45 
12.2.5. 
Primary Efficacy Endpoint ....................................................................................................... 46 
12.2.6. 
Secondary Efficacy Endpoints .................................................................................................. 46 
12.3. 
Sample Size Considerations ..................................................................................................... 47 
12.4. 
Statistical Analysis ................................................................................................................... 47 
12.4.1. 
Overview .................................................................................................................................. 47 
12.4.2. 
Disposit ion of Study Infants ..................................................................................................... 48 
12.4.3. 
Baseline Comparability ............................................................................................................ 48 
12.4.4. Safety 
....................................................................................................................................... 48 
12.4.5. 
Primary Efficacy Endpoint ....................................................................................................... 48 
12.4.6. 
Key Secondary Endpoint .......................................................................................................... 48 
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12.4.7. 
Other Secondary Endpoints ..................................................................................................... 49 
12.4.8. 
Analyses of Predictor Variables ............................................................................................... 49 
12.4.9. 
Sensitivity Analysis: Missing Values ......................................................................................... 50 
12.4.10. Sensitivity Analysis: The second born Twin ............................................................................. 50 
12.4.11. Sensitivity Analysis: The PP Set ............................................................................................... 50 
12.4.12. Interim Futility Analysis ........................................................................................................... 50 
13. 
DATA MANAGEMENT ...................................................................................................................... 51 
13.1. 
Source Data ............................................................................................................................. 51 
13.2. 
Access to Data ......................................................................................................................... 51 
13.3. 
Data Recording and Record Keeping ....................................................................................... 52 
14. 
STUDY MONITORING ....................................................................................................................... 52 
15. 
ETHICAL AND REGULATORY CONSIDERATIONS ............................................................................... 53 
15.1. 
Declaration of Helsinki ............................................................................................................. 53 
15.2. 
ICH Guidelines for Good Clinical Practice ................................................................................ 53 
15.3. 
Approvals, Information on Study Infants, and Consent Form ................................................. 53 
15.4. 
Data Quality Assurance ........................................................................................................... 53 
15.5. 
Participant Confidentiality, data disclosure and publication .................................................. 54 
15.6. 
Expenses and Benefits ............................................................................................................. 54 
16. 
RETENTION OF STUDY DOCUMENTS ............................................................................................... 55 
17. 
FINANCE AND INSURANCE .............................................................................................................. 55 
17.1. 
Funding .................................................................................................................................... 55 
17.2. 
Insurance ................................................................................................................................. 55 
18. 
PUBLICATION POLICY ...................................................................................................................... . 
55 19. REFERENCES 
················· ................................................................................................................... 56 
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LIST OF TABLES 
Table 1: Study Procedures .......................................................................................................................... 31 
Table 2: Severity Assessment Terminology for Reporting Adverse Events ................................................ 41 
Table 3: Contact Information for SAE Reporting ........................................................................................ 42 
LIST OF FIGURES 
Figure 1: Study Flow Diagram ..................................................................................................................... 22 
LIST OF APPENDICES 
Appendix B: Study Flow Diagram ............................................................................................................... 59 
Appendix C: SAE Reporting Flow Chart ...................................................................................................... 60 
Appendix D: Fenton Preterm Growth Chart ............................................................................................... 61 
Appendix E: Expected Complications Related to Premature Birth ............................................................. 63 
Appendix F: Example for TBV volume ........................................................................................................ 65 
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1. 
KEY TRIAL CONTACTS 
Chief investigator 
Prof. Hans Van Goudoever 
AMC Meibergdreef 9, 1105 AZ Amsterdam Zuid-Oost, Netherlands 
Sponsor 
Pharmacovigilance 
Medical Monitor 
2. 
SYNOPSIS 
TITLE 
A Multi-center, Double-blind, Randomized, Three-Arm, Parallel-Group, 
Placebo Controlled Study to Assess the Efficacy and Safety of NTRA-
2112 on Intestinal Malabsorption in Preterm Infants 
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STUDY DESIGN 
PRIMARY 
OBJECTIVE 
The study will evaluate the efficacy and safety of 2 dose levels of 
NTRA2112 on intestinal malabsorption in preterm infants as compared 
to placebo. 
NTRA-2112 is a powder of insulin formulation for reconstitution in 
breast milk, 
infant formula, 
normal 
and 
half-normal 
saline 
administered concomitantly with preterm infant's formula, donor 
breast milk, or own mother's breast milk for local gastrointestinal (GI) 
therapy. 
For both dose levels, the final obtained insulin concentration in the 
infant's nutrit ion is within physiological levels present in human breast 
colostrum milk and amniotic fluid during pregnancy. 
The study will enroll preterm infants weighing at least 500g born 
betw een 26 and up to 32 weeks of pregnancy who meet the inclusion 
and exclusion criteria. 
The effect on intestinal malabsorption will be evaluated by comparing 
the ability of preterm infants to achieve full enteral (EN) feeding for 3 
consecutive days. 
Infants will be treated for 28 days or until hospital discharge, the 
earliest. Patients would receive NTRA-2112 Treatment A to obtain 400 
µU/ ml -
equivalent dose of insulin or NTRA-2112 Treatment B to 
obtain 2000 µU/ ml dose of insulin or placebo as calculated according 
to planned daily enteral intake. 
During the treatment period, infants will undergo daily evaluation of 
AEs, concomitant medication, nutrition, general growth, gastric 
residuals, and development progression. 
Infants will be evaluated at day of discharge. Follow-up visits will be 
performed at 3 months, 12 months and 24 months corrected age. 
Infants will be permitted infant formula, donor breast milk (DBM) and 
own mother's milk (OMM). 
To assess the efficacy of 2 doses of NTRA-2112 as compared to placebo 
on intestinal malabsorption in preterm infants as measured by the 
t ime to full enteral feeding*. 
*Defined as time to reach 3 consecutive days of EN feeding ~150 
ml/kg/ day 
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SECONDARY 
OBJECTIVES 
Key secondary objective: 
To assess the effect of 2 doses of NTRA-2112 compared to placebo on 
number of days to achieve discharge from hospital or readiness for 
discharge from hospital, whichever comes first. 
Readiness for 
discharge from the hospital is defined as achieving all of the below: 
• 
Infant weight ~1800g 
• 
Stable body temperature* 
• 
Capable of oral intake (reached full enteral feeding and not 
dependent on PN) 
Other secondary objectives: 
To compare 2 doses of NTRA-2112 to placebo with respect to the 
following: 
1. Growth parameters 
2. Number and percentage of infants reaching full enteral 
feeding within 6, 8, and 10 days from initiation of treatment 
3. Mean enteral feeding (ml/kg) on days 6, 8 and 10 from 
initiation of treatment 
Exploratory secondary objective: 
To compare 2 doses of NTRA-2112 to placebo with respect to the 
number of days to end gastric residuals over 2ml/measurement. 
* No external support needed 
SAFETY OBJECTIVES 
To compare the safety of 2 doses of NTRA-2112 to placebo in preterm 
infants. 
STUDY DESIGN 
STUDY ARMS 
DURATION OF 
TREATMENT 
DURATION OF 
FOLLOW-UP 
STUDY 
POPULATION 
Multi-center, double-blind, randomized, three-arm, parallel-group, 
placebo-controlled. 
Treatment A: 
NTRA-2112 TREATMENT A, 0.04 IU/ g to obtain 400 µU/ ml daily 
enteral intake administered with preterm infants' nutrition 
Treatment B: 
NTRA-2112 TREATMENT B, 0.2 IU/ g to obtain 2000 µU/ ml daily 
enteral intake administered with preterm infants' nutrition 
Treatment C: 
Placebo oral formulation administered with preterm infants' nutrition 
Up to 28 treatment days or discharge from the hospital, whichever 
occurs first. 
24 months corrected age. 
Duration would be dependent on the 
gestational age at birth of the infant. 
Pre-term infants 26-32 weeks gestation and birth weight ~ 500g, up to 
day 5 of life 
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INCLUSION CRITERIA 1. Male or female pre-term infant 26 and up to 32 weeks gestation 
(32 weeks+ 0 day maximum). Gestational age matching (±2 
weeks) between maternal dates and/ or early antenatal ultrasound 
* 
2. Birth weight ~ 500g 
3. Singleton or tw in birth 
4. Post natal age up t hrough and including Day 5 (up to 120 hours 
post birth) 
5. Fraction of inspired oxygen ~ 0.60 at enrolment 
6. Subjects must demonst rate cardiovascular stability at time of 
enrolment and would be considered unstable if they require >40% 
oxygen with blood pressure support and t he need for umbilical 
art ery cauterization 
7. Infant is able to tolerate enteral feed 
8. Infant is expected to wean off parenteral nut rit ion (PN) at t he 
primary hospital 
9. Informed consent form signed by parents or legal guardian 
10. In t he Investigator's opinion, t he infant is able to comply wit h t he 
study procedures and sufficiently stable to partake in the t rial to 
completion 
* If both exist and difference > 2 weeks, based on early antenatal ultrasound 
EXCLUSION 
1. Complete enteral feeding 
CRITERIA 
2. Major congenital malformation (e.g., infants w ith genetic, 
metabolic, and/ or endocrine disorder diagnosed before 
enrolment ) 
3. High index of suspicion of infection before enrolment ** 
4. Int ra-uterine growt h retardation (IUGR) defined as either weight 
for gestational age less than the third percent ile or less than the 
10th percentile w ith Doppler abnormalities in utero ***, 
5. Confirmed necrotizing enterocolitis (NEC) 
6. Maternal diabetes (Type 1/11 or gestational) requiring insulin 
during pregnancy or in mothers past medical history. 
7. Hyperinsulinemia requiring glucose administration of more than 
12mg/ kg/ min at randomization. 
8. Any systemic insulin administration at randomization. 
9. Nothing per os (NPO) for any reason at study entry. 
10. Heart and chest compression or any resuscitation drugs given to 
t he infant during delivery 
11. Subjects at risk for significant GI complications such as twin-totw in 
t ransfusion syndrome (TTTS) or monochorionic monoamniotic 
twins. 
12. Participation in another interventional clinical study that may 
interfere with the results of this t rial 
**Defined as positive blood culture, Leukocytosis >30,000 and Leukopenia <4,000. 
***According to Fenton preterm growth chart (see Appendix D). If no Doppler in 
utero is available for infants with IUGR between third and 10'th percentile of Fenton 
preterm growth charts, infant is eligible to participate in the study. 
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SAMPLE SIZE 
The study will be comprised of approximately 150 infants per group or 
450 infants in all. Each infant will be assigned one of the tw o doses of 
the study medication (NTRA-2112) or placebo. 
If both members of a pair of twins are eligible for t he study, both twins 
will receive the same randomization assignment, but only the first born 
of the two twins will be part of the analysed cohort for primary efficacy 
analysis. Assuming up to 30% of the cohort are twin pairs, up to 
approximately 530 infants are expected to be treated. 
PRIMARY 
Numbers of days to achieve full enteral feeding, defined as t he ability 
ENDPOINT 
of the preterm infant to achieve enteral feeding at least 150 ml/kg/ day 
for 3 consecut ive days. 
SECONDARY 
Key secondary endpoint: 
ENDPOINTS 
Number of days to discharge from the hospital or readiness-
fordischarge from hospital, whichever occurs first 
Readiness-for-discharge is defined as meeting all the following 
criteria: 
1. Infant weight 2:: 1800g 
2. Stable body temperature 
3. Capable of oral feeding (reached full enteral feeding and not 
dependent on PN) 
Additional secondary endpoints: 
4. Growth velocity (g/ kg/ day) 
5. Change in 2-score at 6, 8 and 10 days from initiation of 
t reatment 
6. Gain in body weight during the t reatment and follow -up 
periods 
7. Number and percentage of infants reaching full enteral 
feeding wit hin 6, 8, and 10 days from initiation of treat ment. 
8. Total number of days receiving parenteral nutrition 
9. Number of days to 120Kcal/kg/ day 
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10. Number of days to wean-off PN1 
Exploratory secondary endpoints: 
11. Number of days to end gastric residuals over 
2 ml/measurement according to the feeding protocol 
(Appendix A). 
12. Gain in length during the treatment period and follow up 
period (long term follow-up period) 
13. Gain in head circumference during the treatment period and 
follow up period (long term follow-up period) 
14. Percent enteral feedings from total nutrition 
15. Percent parenteral nutrit ion from total nutrition 
1 Wean off PN is defined as complete cessation of PN support. 
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PROCEDURES 
SAFETY 
EVALUATION 
NUMBER OF 
CENTERS 
The study physician will follow a recommended feeding protocol 
(Appendix A). The final feeding scheme is subject to the physician's 
clinical evaluation. 
Screening procedures 
After the parent or guardian signs the Informed Consent Form 
(ICF), all inclusion/ exclusion criteria will be checked for eligibility. 
A complete medical history and physical examination will be 
performed. 
Within 24 hours of the screening procedures, eligible infants will 
be randomly assigned to one of the three treatment groups. 
Treatment procedure 
During the treatment period, the infants will receive study medication 
with their enteral feeding (own mother's milk (OMM), donor breast 
milk (DBM), or infant formula) until discharge from the hospital or up 
to 28 days, whichever occurs first. The infant will not be treated more 
than 28 days. During the 28-day treatment period, the investigator 
will evaluate the infant for discharge or readiness for discharge from 
hospital, whichever occurs first. 
The powder will be administered preferably with all daily enteral 
feedings, but at least four times each day at enteral 
feedings.Commencement of the treatment period for infants who 
are fed solely on OMM should not begin within the first 72 hours 
post birth. 
Follow up period: 
The infants will return to the clinical site for a follow-up visit at 3 
months, 12 months, and 24 months corrected age. 
Baseline safety assessment will be performed during the screening 
period and throughout the study (see Table 1): 
1. Physical examination (PE) 
2. Blood chemistry and haematology 
3. Vital signs 
During the treatment period, adverse events (AEs), PE, and vital signs 
will be assessed and recorded in the source documentation and 
electronic case report form (eCRF). These would include episodes of 
NEC, sepsis, meningitis, hypoglycemia and death. 
Monitoring of glucose levels will be performed during the treatment 
period. 
Approximately up to 40 sites worldwide (European countries, United 
States of America, Israel, and possibly other countries). 
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3. 
DEFINITIONS 
Cardiovascular stability 
Day (24 hours) 
Enteral feedin 
EN 
calculating corrected age) 
Gastric residual 
Gestational diabetes 
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Normal pulse, blood pressure, and breath; clinically not significant 
From 00:00/ 12:00am until 23:59/ 11:59pm 
A method of nutrition delive 
w here fluid is iven directl into the 
gastrointestinal tract. 
consecutive days. 
40 weeks gestation should be considered a full term pregnancy. 
Any leftover nutrition in the stomach that w as not digested or 
absorbed by the body. In hospitals where it is captured as standard 
of care, w hen the infant is treated with an orogastric tube, before 
every meal the nurse checks if any residuals were not absorbed and 
e prior mea. 
Diagnosis glucose values for gestational diabetes according to WHO: 
Oral glucose tolerance test (OGTT) 75 g 
• 
Fasting: 
126 mg/ di 
• 
Two hours: 
140 mg di 
High index of suspicion for 
Occurrence of one or more of the follow ing conditions: 
infection 
(1) Positive blood culture; 
(2) Leukocytosis > 30,000 (when accompanied by a negative 
Hyperglycemia 
Blood glucose level above 150 mg/ di 
Intra-uterine growth Weight fo 
an pl0 with Doppler retardation 
(IUGR) 
Parenteral nutrition (PN) 
Total parenteral nutrition 
(TPN) 
Trophic feeding 
bloody stools, or dilated loops of bowel that leads to cessation of 
enteral feedings. 
Nutrition provided intravenously. 
TPN is a way o supp ying a t e nutritiona 
bypassing the digestive system and dripping nutrient solution directly 
into a central vein. 
Feeding of small quantities. 
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4. 
ABBREVIATIONS 
AOL 
AE 
AR 
BPD 
BW 
CRA 
CRF 
CR0 
CA 
CP 
CT 
CTCAE 
DBM 
OS 
DMC 
eCRF 
EN 
FAS 
FDA 
FEF 
GA 
GCP 
GI 
HS- PDA 
IB 
ICF 
ICH 
IEC 
IMP 
IRB 
IUGR 
MedDRA 
ND 
NEC 
NFE 
NGT 
Activities of Daily Living 
Adverse event 
Adverse reaction 
Bronchopulmonary dysplasia 
Birth w eight 
Clinical Research Associate (Monitor) 
Case Report Form 
Contract Research Organisation 
Competent Authority 
Cerebral Palsy 
Clinical trials 
Common Terminology Criteria for Adverse Events 
Donor breast milk 
Dextrose stick 
Data Monitoring Committee 
Electronic Case Report Form 
Enteral nutrition 
Full Analysis Set 
Food and Drug Administration 
Full Enteral Feeding 
Gestational Age 
Good Clinical Practice 
Gastrointestinal 
Hemodynamic Significant Patient Ductus Arteriosus 
Investigator's Brochure 
Informed Consent Form 
International Conference of Harmonisation 
Independent Ethics Committees 
lnvestigational Medicinal Product 
Institutional Review Board 
Intra-uterine growth retardation 
Medical Dictionary for Regulatory Activities 
Not done 
Necrotizing enterocolit is 
Number of days to full enteral feeding 
Nasogast ric tube 
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NICU 
NPO 
NRD 
OGT 
OGTT 
OMM 
PDA 
PE 
Pl 
PN 
pp 
RDS 
ROP 
SAE 
SAP 
SAR 
SmPC 
SUSAR 
TBV 
TMF 
TPN 
TTTS 
WHO 
Neonatal intensive care unit 
Nothing per os 
Number of days to discharge from the hospital 
Orogastric tube 
Oral glucose tolerance test 
Ow n mothers milk 
Patent ductus arteriosus 
Physical examination 
Principal Investigator 
Parenteral nutrition 
Per protocol 
Respiratory Distress Syndrome 
Retinopathy of Prematurity 
Serious adverse event 
Statistical Analysis Plan 
Serious Adverse Reaction 
Summary of Product Characteristics 
Suspected unexpected serious adverse reaction 
Total Blood Volume 
Trial Master File 
Total parenteral nutrition 
Twin-to-twin transfusion syndrome 
World Health Organization 
5. 
BACKGROUND AND RATIONALE 
5.1. General Introduction 
Preterm infants have an under-developed gastrointestinal (GI) tract due to an abrupt disruption of 
pregnancy. 
During an essential but short t imeframe, preterm infants can compensate for their 3rd 
trimester lost growth and development, at w hich t ime they are at high risk for intestinal malabsorption 
due to their malfunctioning GI tract and other complications. That leads preterm infants to dependency 
on prolonged parenteral nutrit ion support (1-3). 
Promoting EN intake at that sensit ive time frame leads to GI maturation and reduces dependence on 
parenteral nutrit ion (PN) with its associated morbidities and complications. Nutrients consumed enterally 
are better absorbed, enhancing vital organ development, improving infants' growth and development 
during the short w indow of opportunity for compensating lost third trimester growth (3). 
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Preterm infants who are born 29 to 32 weeks of gestational age find it very difficult to coordinate suckling, 
swallowing, and breathing regularly. Therefore, they are fed mostly by nasogastric tube (NGT) and as a 
result of their under-developed GI they are placed on PN for a prolonged period of time to avoid 
complications and growth retardation. Smaller preemies cannot perform suckling at all. A meta-analysis 
of 21 articles regarding PN in preterm infants showed that the relevant average gestational age for PN is 
below 32 weeks. Preemies 33 to 36 weeks can usually feed for themselves (2). 
Insulin is one of the biologically active factors in breast milk. During the first days of life, colostrum 
mother's milk contains higher levels of insulin and other bioactive components than mature maternal milk 
does. 
Accumulating evidence indicates that insulin determines important physiological effects on 
intestinal growth, cell maturation, and enzyme expression in several mammalian species (4, 5). 
The perinatal period is crit ical for human development. The brain of preterm infants, who are born 
generally with weight of less than 1,500g, is particularly vulnerable to under-nutrition. Enteral nutrition is 
of major importance for the growth and the development of the GI tract, which depends on the amount 
and composition of feeds. Thus, the goal in preterm infants is fast transition to EN and enable full enteral 
feeding as soon as possible (3). 
Term infants undergo rapid growth in the third trimester of pregnancy, receiving nutrition through the 
placenta and swallowed amniotic fluid with no need to expend calories for temperature regulation or gas 
exchange. Preterm infants miss out on much or all of the third trimester and thus have higher nutrit ional 
requirements on a per kilogram basis than term infants. Human milk nourishes the term infant who can 
tolerate large fluid volumes, whereas preterm infants are less tolerant of high fluid volumes (3). 
For these reasons, human milk usually requires fortification for nutritional adequacy in preterm infants. 
Human milk varies widely in the energy and protein content as well as in other key nutrients. Thus, 
supplementing human milk is a current practice at NICUs. 
A newborn infant's GI tract is naturally exposed to insulin by consuming own mother's milk present 
mainly in colostrum after birth. Importantly, in utero the GI tract is also exposed to insulin levels present 
in the amniotic fluid consumed by the fetus generating a constant flux of insulin stimulating the GI tract. 
As of week 26 gestational age, when skin keratinization is achieved (6), the fetus is exposed to the 
amniotic fluid ingredients such as insulin mainly through the GI tract at ~450 ml of amniotic fluid a day. 
Insulin levels in own mother's milk drop from 1,000-2500 µU/ ml to a ~ 50-90 µU/ ml after the colostrum 
period (48 hours post-delivery); levels are not significantly influenced by gestational age. Thus, just as 
human milk is supplemented with proteins and other key nutrients for preterm infants, Nutrinia proposes 
to supplement human milk with insulin. 
Own mother's milk contains nutritional ingredients as well as various peptides such as insulin. 
Observations on lactating dams and suckling rats have shown that milk-borne insulin is biologically active, 
and that immature enterocytes have an increased responsiveness to insulin (7). 
Shehadeh et al. have 
shown that human milk contains high concentrations of insulin and that insulin is hardly detectable in 
infant formulas (8, 9). 
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Insulin stimulates intestinal epithelial cell proliferation, and ileal lactase activity is increased when porcine 
insulin is added to newborn piglets' feedings (4, 10). Shulman, et al. demonstrated that enteral insulin 
administration may be of benefit in reducing feeding intolerance in preterm infants (11). Thus, orally 
administered insulin is expected to demonstrate a beneficial influence on gut development. 
The NTRA-2112 pow der is mixed with saline, preterm infant's formula, own mother's breast milk or 
pasteurized breast milk (donor breast milk) for enteral administration. Natural insulin activity level is lost 
in pasteurized breast milk and absent in formula. The final insulin concentration obtained with NTRA-2112 
in the infant's nutrition is physiological and within the range of known local gut exposure to insulin levels 
in amniotic fluid and own mother's milk. 
During the past decade neonatologists have made major efforts to reduce feeding intolerance and t ime to 
full enteral nutrition because of the importance of reducing complications and enhancing development of 
vital organs in preterm infants. Major efforts include the introduction of donor breast milk (DBM) as well 
as improvement of preterm infant formula composition and other supplementations to mother's milk. 
NTRA-2112 is aimed at further improving preterm infant progression to enteral autonomy, reducing risks 
and improving infant development in this crucial window of opportunity. 
Preliminary data in preterm infants receiving 4 IU/ kg/ day insulin enterally from 4 to 28 days of age, suggest 
that enteral insulin administration increases lactase activity and may be of benefit in reducing feeding 
intolerance without inducing hypoglycaemia or other adverse effects (11). 
The administration of insulin to preterm infants' enteral nutrit ion proposed in this study will allow 
assessment of the influence of insulin on gastrointestinal maturation and on blood levels of lipids and 
glucose. 
As described in the following paragraphs, administration of oral insulin to preterm infants, low birth weight 
infants, humans and animals, at concentrations up to 1,000 t imes higher than those proposed in this study, 
demonstrated the safety of oral insulin administration. 
Nutrinia conducted a Phase I safety study in 11 low birth weight healthy infants in tw o centers in Israel 
(INFOR 1). All eleven received NTRA-2112 for 4 months, as in the proposed study, administered within 
infant nutrition. No treatment related adverse events were observed in any of the 11 infants. The 
consumption of insulin did not cause hypoglecemia and did not stimulate the production of anti-insulin 
antibodies. 
Nutrinia also conducted an efficacy Phase I study designed as double-blind, randomized, placebocontrolled 
trial to compare NTRA-2112 to placebo on GI development when added to infants' nutrit ion (infant 
formula) (INFOSUP I). The primary evaluation of gastrointest inal maturation was the ability of the preterm 
infants to achieve full enteral feeding (150ml/kg/day). Other objectives included assessment of whether 
NTRA-2112 led to reduction in the number of days to discharge from the neonatal ward, measurements 
of weight gain, and assessment of safety. The insulin concentration administered for 28 days in the study 
was within the insulin concentration range present in low range maternal colostrum (400 µU/ ml) and as 
proposed for the current study. The study comprised eight preterm infants, gestational age: 26-33 weeks 
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BW: > 750g were recruited during the study. The gestational age was 27-31 weeks for the control group 
and 30-31 for the treatment group. Infants in the treatment group reached full enteral feeding earlier, 
gained more weight during the treatment period than the control group, were discharged on average 
earlier, and were free of central line nutrit ion (TPN) earlier. 
A Phase 11, multi-center, double-blind, randomized controlled clinical trial is currently being finalized in 
Israel (INFOSUP II). The study's objective w as to evaluate further the effect of NTRA-2112 on preterm 
infants' gastrointestinal maturation. Inclusion criteria included gestational age between 26 and 33 
weeks and birth weight~ 750g. NTRA-2112 effect on GI development is evaluated by number of days to 
reach full enteral feeds (150 ml/kg/ day). As in the proposed study, NTRA-2112 0.04 IU/ g is used to 
prepare a 400 µU/ ml solution of insulin for dosing over a 28-day period. The stock solution is added to 
standard formula or milk to administer to the infant. The analysed data constitute about 45% (n=33) of 
the planned sample size. The data set includes twins {10 pairs) and singleton births (6 in the control 
group and 7 in the treatment group). An interim study analysis demonstrated shorter time to reach full 
enteral feeding as compared to placebo as w ell as benefit on other efficacy parameters related to 
infants' growth. Interim analysis was performed for the group and separately for twins and singletons. 
Mixed model analysis showed no effect of birth (singleton or multiple) on outcome. No drug related 
adverse events have been reported in this study. 
5.2. Rationale and Justification for the Study 
Knowledge of the risks caused by preterm infants' underdeveloped GI tract is described above. Nutrinia 
developed NTRA-2112 to fulfil the important role of enhancing the preterm infant's capacity for absorption 
in the GI tract, and reduce intestinal intolerance and malabsorption, therefore reducing dependence on 
parenteral nutrit ional support, improving development of vital organs, and reducing catheter-associated 
bloodstream infections and other associated complications. 
A new born infant's GI tract is naturally exposed to insulin by consuming own mother's milk present mainly 
in colostrum after birth. Importantly, in utero the GI tract is also exposed to insulin levels present in the 
amniotic fluid consumed by the fetus generating a constant flux of insulin stimulating the GI tract. As of 
week 26 gestational age, when skin keratinization is achieved, the fetus is exposed to the amniotic fluid 
ingredients such as insulin mainly through the GI tract at "'450 m l of amniotic fluid a day (6). 
Thus, the choice of therapeutic dose levels for preterm infants should compensate for both intrauterine 
and extrauterine insulin exposure. Moreover, average colostrum insulin content suffices for stimulation 
of a term infant's GI for enteral/oral feeding, w hile the preterm infant GI tissue takes several weeks to 
compensate for the disruption of pregnancy and critical intrauterine GI development occurring at the last 
trimester of pregnancy (Investigator's Brochure Section 1.6). 
Although human milk is recommended for preterm infants, it does not provide optimal nutrit ion by itself. 
The growth and neurodevelopmental needs of the preterm infants are best met by appropriate 
fortification of enteral nutrition including own mother's milk. Moreover, mothers of preterm infants 
produce only a few drops of colostrum at each expression for the first 24-48 hours after birth; 
consequently, OMM is a poor provider of essential nutrients and bioactive proteins (such as insulin). 
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Roughly three days after delivery, the insulin levels in OMM drop from 1,000-2500 µU/ ml to ~soµU/ ml. 
Thus, similar to way human milk is supplemented with proteins and other key nutrients for preterm 
infants, Nutrinia proposes to supplement human milk with insulin. Infant's formula, DBM, or a mix of these 
sources needs to be compensated, as natural Insulin activity level is lost in pasteurized breast milk and 
absent in formula. 
Tw o dose levels will be assessed versus placebo: 
* 
NTRA-2112 Dose level 12 : 0.04 IU/ g powder formulation (0.5-g stick pack) is reconstituted to 
achieve 400 µU/ ml of planned daily enteral feeds 
* 
NTRA-2112 Dose level 23: 0.2 IU/ g powder formulation (0.5-g stick pack) is reconstituted to achieve 
2000 µU/ ml of planned daily enteral feeds 
The choice of the tw o dose levels is based on safety profiles and evidence of efficacy demonstrated in five 
independent clinical trials and several non-clinical studies. 
The dose levels, w ere selected within the range of known local gut exposure to insulin levels in amniotic 
fluid and own mother's milk to compensate for physiological intestinal insulin exposure. Both dose 
levels have been demonstrated safe in preclinical trials. NTRA-2112 Dose level 1 was assessed in 
previous clinical studies and was found to be safe and efficacious in the proposed patient population. 
Nutrinia and its scientific advisors have conducted clinical trials in preterm infants, small for gestational 
age infants, and short bowel infants and children with three dose levels (investigator's Brochure Section 
4) of orally administered insulin in the course of five separate clinical trials. In these studies, the dose of 
insulin ranged from 0.01 U/ kg/ day to 4.0 U/ kg/ day. These doses correspond to an equivalent dose of 90 
to 4,000 µU/ m l. As previously described these doses are equivalent or higher than the current target dose 
of NTRA-2112 which would correspond to an exposure or 400 or 2000 µU/ ml. Further supporting the dose 
selection is the duration of treatment (28 days) in 4 of the 5 studies. The duration in study INFOR 1 w as 4 
months, while the other clinical trials durations were 28 days. These durations, coupled with the dose 
described above, support the safe administration of NTRA-2112. 
In summary, the accumulated clinical safety and efficacy results in preterm infants dosed with similar and 
significantly higher orally-administered insulin levels as compared to the current proposed study strongly 
support further clinical development of NTRA-2112 as a path to reduce intestinal malabsorption in preterm 
infants. 
2 NTRA-2112 dose level 1 was used in the Phase I & II trials with NTRA-2112 equivalent to 
0.04 U/kg/day (based on 1 kg body weight and 100 ml daily enteral nutrition). 
3 equivale nt to 0.2 U/kg/day (based on 1 kg body weight and 100 ml daily ente ral nutrition) 
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6. 
STUDY OBJECTIVES 
6.1. Primary Objective 
To assess the efficacy of 2 doses of NTRA-2112 as compared to placebo on intestinal malabsorption in 
preterm infants as measured by the time to full enteral feeding. 
Note: days to full enteral feeding will be regarded as the time to 3 consecutive days consumption of at 
least 150 ml/kg/ day enteral feeding. 
6.2. Secondary Objectives 
Key secondary objective: 
To assess the effect of 2 doses of NTRA-2112 compared to placebo on the number of days to achieve 
discharge from hospital or readiness for discharge, w hichever occurs first. 
Readiness for discharge from hospital defined as achieving all of the below: 
1. 
Infant weight 2: 1800g 
2. Stable body temperature 
3. Capable of oral feeding (reached full enteral feeding and not dependent on PN). 
Other secondary objectives: 
To compare 2 doses of NTRA-2112 to placebo with respect to the follow ing: 
4. Growth parameters (g/ kg/ day) 
5. Change in 2-score at 6, 8 and 10 days from init iation of treatment 
6. Gain in body weight during the treatment and follow-up periods 
7. Number and percentage of infants reaching full enteral feeding within 6, 8, and 
10 days from initiation of treatment 
8. Total number of days receiving parenteral nutrit ion 
9. Number of days to 120Kcal/kg/ day 
10. Number of days to wean-off PN4 
Exploratory secondary objective: 
1. Number of days to end gastric residuals over 2 ml/measurement according to the feeding 
protocol (Appendix A). 
4 Wean off PN is defined as complete cessation of PN support. 
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6.3. Safety Objective 
To compare 2 doses of NTRA-2112 to placebo in preterm infants. 
7. 
STUDY DESIGN 
The study is designed as a multi-center, double-blind, randomized, three-arm, parallel-group, 
placebocontrolled study to assess the efficacy and safety of NTRA-2112. 
Infants will be enrolled within 5 days from birth (at least 6 hours post birth and up to 120 hours post 
birth) and will be treated for 28 days or until hospital discharge (whichever comes first). The study also 
includes a follow-up period up to 24 months corrected age. Figure 1 and Appendix B includes a detailed 
study flow diagram. 
Full enteral feeding is defined as reaching 3 consecut ive days in which the infant consumed at least 150 
ml/kg/ day of enteral nutrition. 
Enrolled infants will be under supervision at a NICU. 
Figure 1: Study Flow Diagram 
Enrollment 
based on 
incl11sion and 
el!ClusJor, cmerl~ 
Randomizahon 
8. 
STUDY POPULATION 
8.1. Study Participants 
NTAA-2112·1{4001,llU lnsulln/mll 
NTRA-2112-2 (2000 µIU IMulln/ml) 
Placebo 
Up to disch.irge from the hospital 
( not more than 28 treatment days) 
Follow U:P period 
Up to 24 months 
corrected a.ce 
Infants up to 5 days old (up to 120 hours post birth), born between 26 and up to 32 weeks of pregnancy, 
weighing at least 500g at birth, and who meet enrolment criteria are eligible for this study. Their parents 
or legal guardian will be asked to sign an informed consent form (ICF) for the study. Only single or twin 
births will be eligible, not triplets or higher. Upon parents' signature of the informed consent form, the 
infants will be screened for eligibility. Once eligibility has been confirmed, the infant will randomly be 
assigned to one of three t reatment groups: low dose or high dose of study medication (treatment A & B) 
or placebo (t reatment C). The study drug (NTRA-2112 or placebo) will be administered with the infant's 
enteral feeds. 
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Eligible infants who are enrolled into the study will be assigned a treatment group randomly. Eligible twins 
will automatically be assigned to the same treatment group. 
All enrolled infants, including both members of a pair twins, should undergo all procedures described in 
this and the following section. 
Pre-term infants will be treated at a NICU and will be under constant supervision during the hospitalization 
period until discharge home. 
8.2. Inclusion Criteria 
1. Male or female pre-term infants 26 and up to 32 weeks gestation (32 weeks + 0 day 
maximum). 
Gestational age matching (±2 weeks) between maternal dates and/ or early antenatal ultrasound*. 
2. Birth weight 2: 500g. 
3. Singleton, or twin birth. 
4. Postnatal age up through and including Day 5 (up to 120 hours post birth). 
5. Fraction of inspired oxygen $ 0.60 at enrolment. 
6. Subjects must demonstrate cardiovascular stability at time of enrolment and would be 
considered unstable if they require >40% oxygen with blood pressure support and the 
need for umbilical artery cauterization. 
7. Infant is able to tolerate enteral feed. 
8. Infant is expected to wean off PN at the primary hospital. 
9. Informed consent form {ICF) signed by parents or legal guardian. 
10. In the Investigator's opinion, the infant is able to comply with the study procedures and 
sufficiently stable to partake in the trial as required until trial completion. * If both exist and 
difference> 2 weeks, based on early antenatal ultrasound 
8.3. Exclusion Criteria 
1. Complete enteral feeding. 
2. Major congenital malformation (e.g., Infants with genetic, metabolic, and/ or endocrine disorder 
diagnosed before enrolment). 
3. High index of suspicion of infection before enrolment** 
4. Intra-uterine growth retardation {IUGR) defined as either weight for gestational age less than the 
third percentile or less than the l0'th percentile with Doppler abnormalities in utero***, 
5. Confirmed necrotizing enterocolitis (NEC).5 
6. Maternal diabetes (Type 1/11 or gestational) requiring insulin during pregnancy or in mothers past 
medical history. 
7. Hyperinsulinemia requiring glucose administration of more than 12mg/ kg/ min at randomization. 
8. Any systemic insulin administration at randomization. 
5 NEC is characterized by t he sudde n onset of gastrointestinal dist ress that may include symptoms such as vomiting, 
abdominal distent ion, bloody stools, or dilated loops of bowel t hat leads to cessation of enteral feedings. 
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9. Nothing per os (NPO) for any reason at the study entry. 
10. Heart and chest compression or any resuscitation drugs given to the infant during delivery. 
11. Subjects at risk for significant GI complications such as twin-to-twin transfusion syndrome (TITS) or 
monochorionic monoamniotic twins. 
12. Participation in another interventional clinical study that may interfere with the results of this trial 
**Defined as positive blood cult ure, Leukocytosis >30,000 and Leukopenia <4,000. 
***According to Fenton preterm growt h chart (see Appendix D). If no Doppler in utero is available for infants wit h IUGR 
between t hird and 10'th percent ile of Fent on preterm growth charts, infant is eligible to participate in t he study. 
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9.5. Discontinuation/Withdrawal of Infants 
9.5.1. Discontinuation Criteria 
Subjects will be discontinued from the study medication after evaluation by the Investigator and Sponsor's 
Medical Monitor in any of the following cases: 
• 
Any CTCAE Grade 3 or 4 adverse event (see Section 11.3) that the investigator considers related to 
study medication and not attributable to the underlying disease or considered common events 
listed in Appendix E. 
• 
Systemic hypersensitivity reaction related to study medication. 
• 
Non-compliance of the subject's parent(s) or legal guardian(s) with study procedures. 
• 
Other reasons regarded as warranting subject's discontinuation from study medication. 
• 
Premature study termination as described below in this section. 
The parent or guardian has the right to w ithdraw the infant from the trial at any time. In addition, the 
Investigator may discontinue an infant from the trial at any time if the Investigator considers it necessary 
for any reason including: 
• 
Non-compliance of the subject's parent(s) or legal guardian(s) w ith study procedures as evaluated 
by the Investigator and/ or Sponsor as warranting subject's discontinuation from study medication 
• 
An adverse event requiring discontinuation of the trial medication or resulting in inability to 
continue to comply with trial procedures 
• 
Other reasons regarded by the Investigator as warranting subject's discontinuation from study 
medication 
• 
Parental withdrawal of consent 
• 
Major congenital malformation - a genetic, metabolic, or endocrine disorder diagnosed after 
enrolment that is known to be congenital 
The reason for withdraw al will be recorded in the source documentation and the eCRF. Parents and 
guardians, if w illing, will be encouraged to return to the site for safety follow-up visits per the study 
schedule in the event of w ithdrawal. 
If withdrawal of the infant is due to an adverse event, the Investigator will arrange for follow -up visits or 
telephone calls until the adverse event has resolved or stabilised. 
• 
If the event causing the withdrawal occurred w ithin the first 28 days of the study and while consent 
is still obtained, the infant w ill stop consuming the study medication; however, the infant w ill be 
followed up and the data w ill be recorded for all remaining study visits up to final study visit at 24 
months corrected age. 
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AEs considered related to the trial medication as judged by a medically qualified investigator and 
all SAEs (related and unrelated to trial medication) will be followed until resolution. Resolution is 
defined as the return to baseline status or stabilization of the condit ion when investigator deems 
further observations or examinations no longer required as medically indicated. 
• 
If the event causing the withdrawal occurred betw een days 28 and the final study visit (follow -up 
visit ), and the event was designated as not product-related, the study withdrawal will be recorded 
with no addit ional follow up. 
9.5.2. Premature Study Termination 
The study subjects are expected to experience many adverse events, including severe adverse events 
related to premature birth, invasive surgery, or other underlying conditions including potential to 
develop NEC. NEC is characterized by the sudden onset of gastrointestinal distress that may include 
symptoms such as vomit ing, abdominal distention, bloody stools, or dilated loops of bowel that leads to 
cessation of enteral feedings. Therefore, all safety concerns potentially leading to study termination will 
be referred to the Data Monitoring Committee (DMC), w hich is responsible for a formal assessment of 
the safety of the study. This Board will propose the appropriate course of action to the Sponsor. 
Individual Events: 
Any of the following individual events would be referred by the study Medical Monitor to the DMC 
chairman for review, who may decide that the events warrant a full DMC review. The DMC w ill review 
these events unblinded to fully evaluate the potential risk to subjects in this trial. Given this is a blinded 
trial, the DMC review is required to consider if the events, both serious and related non-serious events, 
are occurring more frequently in the active arms and to judge whether there is a meaningful likelihood 
that these events are drug-related. The DMC may recommend to the Sponsor to stop the study, or any 
portion of it, at any t ime for safety reasons on the basis of their review. Individual events that may 
trigger a DMC review based on individual cases: 
• 
Two or more cases of Grade 3 or greater allergic reactions or anaphylaxis, that the investigator 
deems as possibly related to study medication; 
• 
Any case of autoimmune disease associated with neutralizing antibodies to insulin and w here 
other related causes, such as Type I diabetes, are ruled out; 
• 
Two or more cases of persistent Grade 3 or greater hypoglycemia that is non-responsive to 
treatment within 72-hours and reoccurs after temporary discontinuation of study medication and 
re-challenged. 
Further, the Medical Monitor will be responsible for review of all reported SAEs in an ongoing manner. 
Any SAE that is deemed potentially related to study medication, or of particular concern by the Medical 
Monitor, will also be sent to the DMC Chairman for review w ithin 15 days. The DMC Chairman may 
decide to bring any individual SAE event that may be related and of concern to the full DMC for review. 
Collective Events: 
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The Medical Monitor and DMC will review aggregate safety data in an ongoing manner, at DMC meetings 
w hich will be held approximately each 4 months throughout the trial. The Medical Monitor will remain 
blinded to treatment assignment for cumulative data at all t imes, but may refer any safety concerns 
based on review of safety data to the DMC for further evaluation. The DMC will receive unblinded safety 
data summaries from an independent statistician that is assigned to prepare the unblinded study reports 
for all subjects at each DMC meeting. The DMC statistician will compare the event rates for AEs 
between the groups and the probability that the groups differ in the frequency of events. If there are 
differences in Grade 3 or higher adverse events that differ materially betw een the active arms and/ or 
placebo, and that may be attributable to study medication based on the mechanism of action of the 
drug, the DMC has the option to recommend that the Sponsor stop the study, or modify the protocol for 
safety reasons. 
The study may also be prematurely terminated for administrative reasons, ethical considerations, at the 
request of local regulatory agencies, or for any other reason the Sponsor deems appropriate. 
10. 
INVESTIGATIONAL MEDICINAL PRODUCT (IMP) 
10.1. 
IMP Description 
The study medications include an active formulation designated NTRA-2112 with human insulin in 2 
different doses as the active pharmaceutical ingredient and a placebo formulation. 
The placebo 
formulation consists of the same inactive ingredients as NTRA-2112. 
NTRA-2112 is incorporated into preterm infant's formula, own mother's milk and pasteurized breast milk 
(donor breast milk) for enteral administration. NTRA-2112 may also be reconstituted with normal (0.9% 
NaCl) or half normal saline (0.45% NaCl) for enteral administration, as described in the pharmacy manual. 
Natural insulin activity level is lost in pasteurized breast milk and absent in formula. The final insulin 
concentration obtained with NTRA-2112 in the infant's nutrition is physiological and within the range 
present in human breast milk and colostrum. 
NTRA-2112 
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Dosage form: 
Powder for oral solution added to own mother's milk, pasteurized breast milk, infant's formula. 
10.2. 
Presentation and Storage Conditions 
O.Sg powder for oral solution in stick packs. The stick packs should be stored at room temperature in a 
cool and dry place (further instructions are available in the Pharmacy Manual). 
10.3. 
Method of Administration 
The NTRA-2112 and placebo powder will be administered for 28 days or until discharge. The product is 
provided in O.Sg stick packs. 
NTRA-2112 TREATMENT A, 0.04 IU/ g to obtain 400 µU/ ml Insulin; NTRA-2112 TREATMENT B, 0.2 IU/ g to 
obtain 2000 µU/ ml insulin; NTRA-2112 mimics the insulin levels in human breast milk and amniotic fluid 
in-utero. NTRA-2112 may be reconstituted with normal saline as described in t he pharmacy manual. 
The powder will be administered preferably with all daily enteral feedings, but at least four t imes each day 
at enteral feedings according to the study definit ions and ent eral feeding protocol only (see Appendix A). 
10.4. 
Concomitant Therapy, Restrictions and Rescue Treatment 
There are no limitations or restrictions on concomitant therapy. 
Rescue medication will be administered according to the Investigator's discret ion. 
In case of overdose, the glucose level should be monitored carefully for 12 hours and treated according to 
Investigator's discretion. 
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10.5. 
Treatment Compliance 
The compliance check will be based on the number of meals to which NTRA-2112 or placebo was added 
(i.e., actually taken) to the infant's planned daily enteral nutrition. Missed doses should not be replaced 
or added. 
Compliance should be emphasised; however, randomized infants will not be discontinued for lack of 
compliance. 
Full or partial dose interruptions are permitted at the Investigator's discretion; interruptions should last no 
longer than 3 consecutive days. 
10.6. 
Packaging and Labelling 
The IMP (NTRA-2112 and Placebo) is packed in stick packs. Secondary carton packaging is provided with 
200 stick packs for each infant, which genera lly is the sufficient amount of stick packs for the entire 
treatment period. Each infant will have a designated carton package of study medication. In case of a 
need, an unscheduled re-supply of additional IMP kit can be assigned to the infant. 
All labelling complies with Volume 4. Good Manufacturing Practices, Annex 13. Manufacture of 
investigational medicinal products, July 2010. 
10.7. 
Storage of Study Medication 
Study medication will be stored at room temperature in the pharmacy or in the neonatal intensive care 
unit, depending on where the institution stores medication and prepared medication for the study infants. 
Further instructions are available in the Pharmacy Manual. 
10.8. 
Accountability of the Study Medication 
Upon receipt of study drugs, the Investigator (or designee) will conduct an inventory count of the supplies. 
The Investigator will retain a copy of this inventory at the site and provide a copy to the study monitor. 
The study monitor may check the inventory of supplies at the study site at any t ime during the study. 
Drug supplies, which the sponsor will provide, must be kept in a secure, limited access storage area under 
the storage conditions defined by the sponsor (see Pharmacy Manual). 
The Investigator, pharmacist and/or investigational drug storage manager will receive the investigational 
drugs when a ll country-specific required approvals are in place and all required country-specific essential 
documents are provided to Nutrinia or its designee. 
The Investigator, pharmacist and/or investigational drug storage manager must maintain records of the 
product's delivery to the trial site, the inventory at the site, the use by each infant, and the return to the 
Sponsor of unused or partia lly used product. These records will include dates, quantities, batch/serial 
numbers, re-test ('use by') dates, and the unique kit numbers assigned to the investigational product and 
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the trial infants' study number. The Investigator, pharmacist and/ or investigational drug storage manager 
w ill maintain records that document adequately that the infants were provided the doses specified by the 
protocol, plus kits assigned by randomization system and reconcile all investigational products received 
from the Sponsor. At the time of return to the Sponsor, the Investigator, pharmacist and/ or investigational 
drug storage manager must verify that all unused or partially used drug supplies have been returned and 
that no remaining supplies are in the Investigator's possession. 
The study monitor is responsible for ensuring that the Investigator (or designee) has correctly documented 
the dispensing of study drugs on the dispensing log. The st udy monitor will perform an inventory of study 
drugs at routine monitoring visits and at the closeout visit to the site. 
11. SAFETY MEASURMENTS 
Safety w ill be evaluated daily during the t reatment period. An addit ional safety evaluation w ill be 
performed at discharge or end of t reatment and at the final study visit (follow-up visit). 
11.1. 
Definitions 
Adverse Event (AE) 
Any untoward medical occurrence in a clinical investigation of a subject 
administered a pharmaceutical product (either test product or cont rol 
product) and that does not necessarily have a causal relationship w ith 
the t reatment. 
An AE is therefore any unfavorable and unintended sign, symptom, or 
disease temporally associated wit h the use of an investigational 
(medicinal) product or other protocol-imposed intervention, regardless 
of attribution, i.e., whether or not related to t hat investigational 
(medicinal) product. An AE may include intercurrent illnesses or injuries 
that represent an exacerbation (increase in frequency, severity, or 
specificity) of pre-existing conditions (e.g., worsening of asthma). 
A laboratory abnormality will be reported on the "Adverse Event" case 
report form only if the investigators considered it clinically significant, or 
if it is associated w ith clinical sequelae or requires therapeutic 
intervention 
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Serious Adverse Event 
A serious adverse event is any untoward medical occurrence that: 
(SAE) 
. results in death 
. is life-threatening 
. requires inpatient hospitalisation or prolongation of existing 
hospitalisation 
. results in persistent or significant disability/incapacity 
Other 'important medical events' may also be considered serious if they 
jeopardise the study infant or require an intervention to prevent one of 
the above consequences. 
NOTE: The term "life-threatening" in the definition of "serious" refers to 
an event in which the infant was at risk of death at the time of the event; 
it does not refer to an event that hypothetically might have caused death 
if it were more severe. 
Serious Adverse Reaction 
An adverse event that is both serious and, in the opinion of the reporting 
(SAR) 
Investigator, believed with reasonable probability to be due to one of 
the t rial treatments, based on the information provided. 
Suspected Unexpected 
A serious adverse reaction, the nature and severity of w hich is not 
Serious Adverse Reaction 
consistent with the information about the medicinal product in question 
(SUSAR) 
described: 
. in the case of a product with a marketing authorisation, in the 
Summary of Product Characteristics (Sm PC) for that product 
. in the case of any other investigational medicinal product, in the 
Investigator's Brochure relating to the t rial in question. 
11.2. 
Causality 
The Investigator will determine the relat ionship of an AE to t he study drug and will record it on the source documents 
and eCRF, using t he categories defined below. 
Causality Category 
Description 
A clinical event, including a laboratory test abnormality, with a temporal 
relationship to drug administration, that makes a causal relationship 
Unlikely 
improbable, and in w hich other drugs, chemicals, or the underlying disease 
provide plausible explanations. For t he purpose of this protocol, t he term 
unlikely will be considered not related to study medication and will be termed 
an "Adverse Event" . 
A clinical event, including a laboratory test abnormality, with a reasonable 
t ime sequence to administration of the drug, but that could also be explained 
Possible 
by concurrent disease or other drugs or chemicals. 
Information on drug 
withdrawal may be lacking or unclear. For the purpose of this protocol, an 
event that has possible relationship to study medication will be defined as a 
"Suspected Adverse Drug Reaction" . 
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Probable 
A clinical event, including a laboratory test abnormality, w ith a reasonable 
t ime sequence to administration of the drug, unlikely to be attributed to 
concurrent disease or other drugs or chemicals, and that follows a clinically 
reasonable response on withdraw al. For the purpose of this protocol, an 
event that has probable relationship to study medication will be defined as 
an "Adverse Drug Reaction" . 
11.3. 
Collecting, Recording and Reporting of Adverse Events and Serious Adverse Events 
Treatment-emergent AEs are events that are not present at screening, or if present at screening, have 
worsened in severity or frequency. 
Data regarding all treatment-emergent AEs will be collected in this study and recorded in the source 
documentation and in the eCRF, whether or not the event is attributed to trial medication. Pre-treatment 
emergent events w ill not be considered as AE and will be recorded as medical history. 
Adverse event monitoring will be captured throughout the study from Day 1 (init iation of dosing) until the 
final study visit (follow-up visit). 
AEs and SAEs w ill be evaluated daily during the treatment period. An additional safety evaluation w ill be 
performed at discharge or end of treatment and at final study visit (follow-up visit). 
The follow ing information will be recorded: description, date of onset and end date, severity, assessment 
of relatedness to trial medication, other suspect drug or device, and action taken. Follow-up information 
should be provided as necessary. The investigator will assess AEs for severity, for relationship to the study 
drug, and as to whether the event meets one or more of the definit ions of an SAE. 
AEs w ill be graded on a 5-point scale (mild, moderate, severe, life-threatening, and death) and reported as 
indicated in the source documentation and in the eCRF. Severity of such an AE is defined as follows: 
Table 2: Severity Assessment Terminology for Reporting Adverse Events 
CTCAE Grade 
Common Term 
Description 
Mild; asymptomatic or mild symptoms; clinical or diagnostic 
1 
Mild 
observations only; intervention not indicated. 
Moderate; minimal, local or noninvasive intervention indicated; 
2 
Moderate 
limiting age-appropriate instrumental Activities of Daily Living 
(AOL). 
Severe 
or 
medically 
significant 
but 
not 
immediately 
3 
Severe 
lifethreatening; hospitalization or prolongation of hospitalization 
indicated; 
4 
Life-threatening 
Life-threatening consequences; urgent intervention indicated. 
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5 
Death 
I Outcome of AE was death 
AEs that are not described on the CTCAE v 4.03 will be graded using the scale in Table 2. 
In order to classify adverse events and diseases, the sponsor or designee will use the Medical Dictionary 
for Regulatory Activities (MedDRA) to assign preferred terms to the original terms entered in the eCRF. 
AEs considered related to the trial medication as judged by a medically qualified investigator and all SAEs 
(related and unrelated to trial medication) must be followed until resolution. Resolution is defined as the 
return to baseline status or stabilization of the condition with the expectation that it will remain chronic. 
The Investigator will use clinical judgment to decide whether or not an AE is of sufficient severity to require 
the study infant's removal from treatment. A participant's parents or legal guardian may also voluntarily 
withdraw from treatment for w hat he or she perceives as an intolerable AE. If either of these occurs, the 
infant must undergo an end of trial assessment and be given appropriate care under medical supervision 
until symptoms cease, or the condition becomes stable. 
All SAEs must be reported to the Sponsor by the Investigator, study coordinator, other designated study 
personnel, or clinical research associate within 24 hours of notification of the SAE for any related SAEs and 
any SAE resulted in death (related or unrelated), and within 48 hours for SAEs unrelated to the 
investigational product, other than death. To report such events, an SAE form must be completed by the 
Investigator and/ or designee and sent by email or fax with relevant information. 
The Investigator or designee must provide further information on the SAE as soon as it is available. This 
should include a copy of the completed SAE form, and any other information that will assist the 
understanding of the event. Significant new information on ongoing SAEs should be provided promptly as 
a follow-up. 
The Investigator and/ or designee also must report all SAEs promptly to the appropriate Independent ethics 
committee (IEC) / Institutional Review Board {IRB) as required by the institution. 
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■ 
1111 
All SAE information must be recorded in ink on the SAE form provided by the Sponsor and then printed 
and signed by the Investigator who completed the SAE form. Additional follow-up information (e.g., test 
results, autopsy, and discharge summary) must be obtained to supplement the SAE report form. A copy 
of all initial and follow-up reports must be filed with the subject's source documentation. 
An SAE reporting flow chart is provided in Appendix C. 
11.4. 
Safety M onitoring Plan 
The Investigator is responsible for the classification of adverse events and together w ith the Sponsor for 
the ongoing safety evaluation of the clinical investigation. 
The sponsor shall: 
• 
Set up a Data Monitoring Committee - An independent DMC will review safety data and will make 
recommendations whether to continue or terminate the study. The DMC analyses and operations 
will be formally separated from the sponsor, the investigators, and the Steering Committee. 
Details on the composition of the committee, its procedures, and its interactions are provided in 
a separate DMC Charter. 
• 
Review the investigator's assessment of all adverse events and determine and document in w riting 
their seriousness and relationship to the study medication; in case of disagreement between the 
sponsor and one or more principal investigator, the sponsor shall communicate both opinions to 
the IEC/ IRB and the national regulatory authorit ies, if required. 
• 
Report or ensure the reporting to the IEC/ IRB by the Pis of all serious adverse events according to 
timelines specified in Section 11.3. 
• 
Report to regulatory authorities, within the required time period, all serious adverse events, if 
required by national regulations. 
Inform all Pis in w riting of all the serious adverse events at all investigation sites that have been 
reported to the sponsor, and ensure that the Pis report them to their IEC/ IRB, if required by 
national regulations; this information shall be sent to all Pis w ithin a time frame established based 
on the perceived risk. 
• 
Ensure that the IEC/ IRB and the regulatory authorities are informed of significant new information 
about the clinical investigation. 
In case of a serious adverse event, determine w hether the risk analysis needs to be updated and 
assess whether corrective or preventive action is required. 
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12. 
SAMPLE SIZE AND STATISTICAL METHODS 
12.1. 
Overview 
This trial aims to assess the efficacy and safety of 2 doses of NTRA-2112 as compared to placebo on 
intestinal malabsorption in preterm infants. The primary efficacy w ill be assessed by comparing the 
distributions of days to full enteral feeding (NFE) between active doses and placebo. Safety w ill be assessed 
by adverse events and safety measurements. 
12.1.1. Design Considerations 
This mult i-center, double-blind, randomized, placebo-controlled study will compare preterm infants 
receiving one of 2 doses of NTRA-2112 to those receiving placebo. Infants will be randomized to treatment 
A or 8 or C using a 1:1:1 ratio. Randomization will be blocked and stratified by tw o levels of gestational 
age: 
26+0 to 28+6 wks 
• 
29+0 to 32+0 weeks 
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The block size will remain blinded to the Sponsor and the Investigators. 
This study allows inclusion of both fraternal and identical twins. For ethical reasons, each twin pair (if both 
are eligible for the study) will be randomized into the same treatment arm. The decision was made after 
consultation with physicians who assert that parents should not be put in a position in which one of their 
twins receives placebo while the other receives NTRA-2112. Because of the possible dependency between 
the outcomes for twins, if both are eligible for the study, the primary analysis will include only the 
firstborn. 6 If only one twin is eligible, then that twin (whether first- or second-born) will be included in the 
primary analysis. 
While only one of the twins will be included in the trial's full analysis set (FAS), throughout the trial period 
all eligible twins will receive the treatment to which they were assigned. The safety analyses will include 
all infants receiving study treatment, whether or not they are members of the FAS. Some additional 
efficacy analyses will include both participating twins and some will include only the second born of the 
participating twins. 
The planned trial is mult i-center; it will be comprised of a large population of infants including twins and 
those given different types of feeding regimens (i.e., OMM, DBM only, formula, combinations). Nutrinia 
knows of no similar study that has been conducted in such a wide-ranging population. The best estimate 
of within-group variation, which is crit ical for correctly computing study power, is based on Nutrinia's 
INFOSUP II - Phase II study with a narrower population. For this current trial, it is important to assess the 
accuracy of our assumption regarding within-group variation because an underestimation of variance has 
the potential to reduce study power substantially. Consequently, a sample size re-estimation procedure 
will be used at the time of the interim futility analysis. The sample size may be increased if the standard 
deviation is at least 5% larger than assumed in the protocol. 
The same statistician who will prepare the analysis for the interim futility calculation will compute the 
average within-group standard deviation; this person will not be involved in any other aspect of the trial. 
The Statistical Analysis Plan, which will be written prior to the futility analysis, will describe in detail the 
method for the estimation of standard deviation and the methods to be used to ensure blinding of study 
statisticians to all information apart from the updated sample size. 
This trial has one primary and one key secondary endpoint. The key secondary endpoint will be formally 
tested only if the data show statistically significant benefit on the primary endpoint. The study is 
6 The non-paramet ric primary analysis does not enable controlling for dependency bet ween siblings as, for example, 
the parametric models can. 
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comparing each of two doses to placebo; a Bonferroni approach will be used to adjust for the two tests of 
the two doses NTRA-2112. 
The key secondary endpoint in this trial is number of days to discharge from the hospital. The decision to 
discharge a preterm newborn from the hospital is based on standard of care and hospital policies, which 
may also include social considerations7• Thus, the key secondary endpoint refers to actual discharge from 
the hospital. Infants not reaching NRD (number of days to discharge from the hospital) due to death or 
complications will, as noted in the preceding paragraph, be excluded from the primary analyses. 
12.2. 
Analysis Sets 
12.2.1. Safety Analysis Set 
The safety analysis set will consist of all infants in w hom any study drug- placebo or NTRA-2112- was 
initiated. If both members of a pair of twins are part icipating in the study, the safety analysis set will 
include both. 
12.2.2. Full Analysis Set (Intention-to-treat) 
The Full Analysis Set will consist of all randomized singletons and, for twins who both participate in the 
study, only the first born. 
12.2.3. Per-Protocol Analysis Sets 
Instead of defining a Per-Protocol (PP) analysis set, modern methods of analysis of PP data that separate 
the reasons for noncompliance from the effect of study drug will be used as per, for example, Robins 
(1989)(12). 
12.2.4. Safety 
Serious adverse events and adverse events occurring at any t ime during the trial or follow-up will be listed 
and summarized. 
The incidence of (1) NEC and (2) death w ill be compared betw een the t reatment groups. 
Safety assessments will include: 
• 
Length of exposure to study medication 
Physical examination and vital signs 
Blood chemistry and haematology 
7 For example, one of a twin pair may remain in the hospital despite readiness for discharge until his/her sibling is 
also ready for discharge, so that both can be discharged at the same time. 
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• 
Concomitant medications 
12.2.5. Primary Efficacy Endpoint 
Numbers of days to achieve full enteral feeding (NFE) is defined as: 
Number of Days to achieve enteral feeding of at least 150 ml/kg/ day for at least 3 consecutive days 
12.2.6. Secondary Efficacy Endpoints 
Key secondary objective: 
To assess the effect of 2 doses of NTRA-2112 compared to placebo on the number of days to achieve 
discharge from hospital or readiness for discharge, whichever occurs first. 
Readiness for discharge from hospital defined as achieving all of the below: 
Infant weight 2: 1800g 
• 
Stable body temperature 
• 
Capable of oral feeding (reached full enteral feeding and not dependent on PN). 
Other secondary objectives: 
To compare 2 doses of NTRA-2112 to placebo w ith respect to the following: 
• 
Growth velocity (g/ kg/ day) 
• 
Change in 2-score at 6, 8 and 10 days from init iation of treatment 
• 
Gain in body weight during the treatment and follow-up periods 
Number and percentage of infants reaching full enteral feeding within 6, 8, and 10 days from 
initiation of treatment. 
• 
Total number of days receiving parenteral nutrition 
Number of days to 120Kcal/kg/ day 
Number of days to wean-off PN8 Exploratory secondary objective: 
Number of days to end gastric residuals over 2 ml/measurement according to the feeding protocol 
(Appendix A) 
*Enteral feeding defined as at least 150 ml/kg/ day for at least 3 consecutive days. 
Exploratory secondary analyses: 
• 
Number of days to end gastric residuals over 2 ml (per feeding protocol Appendix A) 
Gain in length during the treatment period and follow up period (long term follow-up period) 
8 Wean off PN is defined as complete cessation of PN support. 
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• 
Gain in head circumference during the treatment period and follow up period (long term followup 
period) 
• 
Percent enteral feedings from total nutrition 
Percent parenteral nutrition from total nutrition 
12.3. 
Sample Size Considerations 
Presentation of sample size is based on the hypothesis that NFE in either treatment group is shorter than 
in the placebo group. Based on limited historical data (phase 2), the conservative mean is 8.0 days for the 
placebo group and 6.6 days for each of the 2 active dose groups. This assumes a standard deviation of 3.5 
days for each group. 
The analysis will be based on a nonparametric test. The NFEs for each infant in the FAS will be ranked from 
shortest time (the best outcome) to longest time. Infants who do not achieve EN because they experience 
NEC will be assigned the next set of ranks; all the infants experiencing NEC will be ranked in terms of their 
time to NEC (the earlier the worse) and will be assigned ranks one greater than the rank of the longest 
time to achieve NFEs. All infants who die will be assigned the next set of ranks, again with the earliest 
deaths assigned the worst rank. Thus, each infant who has achieved EN or w ho has died or suffered NEC 
will have an observed rank. 
Study Infants will be randomized by center and by gestational age group. The statistical analysis will stratify 
the infants by gestational age group and region (United States and Europe), but not by center. Because 
the analysis will be based on ranks, a Van Elteren test will be used to compare NTRA-2112 to placebo. To 
calculate sample size, an independent groups t-test for 85% power to account for the reduced power of 
the non-parametric test was used (i.e., expect that at-test with 85% power to have at least 80% w hen the 
Van Elteren test is applied). A 2.5% significance level to account for 2 dose comparisons to placebo was 
used. These calculations give N = 136 infants per group. To account for the reduction in power caused by 
potential missing data, the sample size was increased to 150 per group or a total sample size of 450. 
Note: The sample size provided in this section relates only to those infants included in the FAS; however, 
the total number of infants treated with NTRA or placebo may be as high as 530, depending on how many 
of the infants in the study are pairs of twins. As described above, the FAS will include only the first born 
infant in a participating pair of twins. The second born sibling will be included in safety analyses and some 
supplementary efficacy analyses. 
12.4. 
Statistical Analysis 
This section briefly describes the statistical analysis planned for the study. A full Statistical Analysis Plan 
(SAP), to be w ritten prior to the futility analysis, will describe the methodology in detail. Should the 
methods in SAP differ from methods in this section, the methods in the SAP will take precedence. 
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Statistical methodology will be consistent w ith ICH and other regulatory guidelines as well as general 
principles of rigorous statistics. 
12.4.1. Overview 
Data listings by infant will be provided. 
The data w ill be summarized in tables listing the mean, standard deviation median, 25th and 75th 
percentiles, minimum, maximum for continuous data, or in tables presenting counts and percentages. 
Tables will be presented by study arm and overall. "Time-to" data w ill be described by survival curves. 
All statistical analyses will be performed and data appendixes will be created using the SASe system or 
other validated softw are. 
12.4.2. Disposition of Study Infants 
Disposit ion of study infants w ill be reported for the FAS and the safety analysis set. Tables will present the 
number of infants enrolled, exposed, prematurely terminated, and completed will be summarized by 
treatment group and overall. A list of dropouts will show the reason for and t ime of discontinuation. 
12.4.3. Baseline Comparability 
Demographic and baseline clinical variables will be presented for infants in each treatment arms using 
tables and figures along w ith descriptive statistics. Treatment groups w ill be compared to evaluate the 
balance achieved by randomisation. Observed differences between the groups, should there be any, will 
be interpreted for their clinical significance and their potential use as covariates in sensit ivity analyses of 
efficacy endpoints. 
12.4.4. Safety 
The safety analyses w ill be descriptive and narrative in nature, w ith SAEs and AEs coded using MedDRA 
and tabulated by body system, preferred term, treatment group, severity, and relation to IMP. Descriptive 
statistics will be provided by treatment group as appropriate. 
12.4.S. Primary Efficacy Endpoint 
The FAS will be used to test the primary efficacy endpoint. 
The primary efficacy analyses (one for each dose) will test the following null and alternative hypotheses: 
Ho: The distribution of the number of days to full enteral feeding is the same in the treated and 
the placebo groups. 
H1: The distribution of the number of days to full enteral feeding differs in the treated and the 
placebo groups. 
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The ranks for any missing values will be calculated using mult iple imputation; the SAP will describe the 
methods in detail. 
The Van Elteren Test will be used for the primary efficacy analysis with data stratified by two Gestational 
age (GA) strata and two regions (North America and Europe). For each dose, the test will be performed 
with a Bonferroni correction, which will maintain the overall two-sided Type I error rate at 0.05. 
The study will have shown benefit of NTRA-2112 if the null hypothesis for either tested dose is rejected 
and NFE is shorter for NTRA-2112 than for placebo. 
12.4.6. Key Secondary Endpoint 
The FAS will be used to test the key secondary efficacy endpoint. 
The key secondary endpoint will be tested only if the primary efficacy analysis shows superiority. For each 
dose that shows superiority for the primary efficacy endpoint, the following hypothesis will be tested: 
Ho: The distribution of the number of days to NRD is the same in the treated and the placebo 
groups. 
H1: The distribution of the number of days to NRD differs in the treated and the placebo groups. 
where NRD = number of days to discharge from t he hospital. 
The ranks for any missing values will be calculated using mult iple imputation; the SAP will describe the 
methods in detail. 
Testing of the key secondary endpoint will be by the Van Elteren test, stratified by region (North America 
and Europe) with a threshold for statistical significance of P<0.025. 
The data will have shown benefit on the key secondary outcome for either dose for which the null 
hypothesis is rejected and the NRD is shorter for NTRA-2112 than for placebo. 
12.4.7. Other Secondary Endpoints 
The other secondary endpoints will be tested in the FAS. For each of these other endpoints, the two-sided 
Type I error rate will be 0.025 for each dose. Statistical testing of these other secondary endpoints will be 
considered exploratory and will not control for Type I error rate. The SAP will describe the methods used 
for these endpoints including the approaches planned for missing data. Long term follow -up data at 12 
and 24 months will be summarised descriptively. Full details will be given in the SAP. 
12.4.8. Analyses of Predictor Variables 
Effect of covariates: The effect on the primary and key secondary outcomes of the following variables will 
be assessed: 
• 
GA 
• 
Birth weight 
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• 
Gender 
• 
Ethnicity 
Enteral feedings type 
1. Own mother's milk only to full enteral feeding 
2. Donor breast milk only to full enteral feeding 
3. Infant formula only to full enteral feeding 
4. Own mother's milk and formula, in any combination of proportions, to full enteral 
feeding 
5. Donor breast milk and formula, in any combination of proportions, to full enteral 
feeding The methodology will be described in the SAP. 
12.4.9. Sensitivity Analysis: Missing Values 
The following sensitivity analyses will be conducted on the primary and key secondary endpoints to explore 
the effect of these missing values: 
• 
Worst reasonable case analysis: Infants in an NTRA-2112 group with a missing rank will be 
assigned the median rank in the placebo group and infants in the placebo group with a missing 
rank will be assigned the median rank in the combined NTRA-2112. 
Best reasonable case analysis: Infants in an NTRA-2112 group with a missing rank will be assigned 
the median rank in the respective NTRA-2112 group and infants in the placebo group with a 
missing rank will be assigned the median rank in the placebo group. 
• 
Tipping point analysis: Infants in any group with a missing rank will be assigned varying ranks to 
find the point at which the results reverse from favoring one treatment group to the other. 
Survival ("time-to-event") analysis: a log rank test will be performed to compare t ime-to-FEF. In 
this analysis, infants who experience NEC will be assigned censoring times of 29 days and infants 
who die will be assigned censoring t imes of 30 days. Any other infants who withdraw from the 
study early will be considered censored at the day of their last participation in the study (unless 
they have already achieved FEF in which case they will not be censored. 
12.4.10. 
Sensitivity Analysis: The second born Twin 
Several analyses will be performed to include the second born twin. 
One analysis will repeat test the primary and key secondary endpoints replacing the first born twin by the 
second born twin. 
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Another approach will be a hierarchical mixed model that includes both twins in a way that accounts for 
the possible correlation between them. The SAP will describe in detail the method to be used, including 
the approach to handle deaths and cases of NEC. 
12.4.11. 
Sensitivity Analysis: The PP Set 
Many physicians are interested in the effect of an intervention on patients who actua lly take the drug. The 
typical approach is to analyze the data in a so-ca lled PP set of data. These analyses are prone to serious 
bias. Nutrinia plans to use modern methods of analysis of PP data that disentangle the reasons for 
noncompliance from the effect of study drug.(12). The SAP will describe these analyses. 
12.4.12. 
Interim Futility Analysis 
The study will include an interim futility analysis as defined in the SAP. For the futility analysis, the 
condit ional power of showing statistically significant evidence of benefit on the primary endpoint will be 
calculated for each dose group. If the conditional power is less than 20% in either dose, continuing to 
enter infants in that dose group will be considered statistically futile. 
An independent statistician will perform the futility analysis. This statistician will not be involved in the 
preparation of the statistical analysis plan or in other aspects of the trial. The statistical analysis performed 
during the futility interim look will be presented as defined in the SAP to an independent Data Monitoring 
Committee (DMC), which will review the results and make a recommendation regarding continuing the 
study, stopping the study, or discontinuing recruitment into one dose group. The DMC will base its 
recommendation on trial continuation on the tota lity of evidence available to it, rather than only on the 
statistical futility criterion. Because the only reason to recommend stopping the study, or stopping one 
dose, is futility (or safety) and not efficacy, this analysis does not compromise the Type I error rate. 
The Sponsor will be blinded to a ll efficacy and safety data. Only the fina l DMC recommendation will be 
provided to the Sponsor. 
13. 
DATA MANAGEMENT 
13.1. 
Source Data 
Source documents are the documents where data are first recorded, and from which participants' eCRF 
data are obtained. These include, but are not limited to, hospital records (from which medical history and 
previous and concurrent medication may be summarised into the eCRF), clinical and office charts, 
laboratory and pharmacy records, diaries, radiographs, and correspondence. 
The Investigator will maintain adequate and accurate source documents designed to record all 
observations and other pertinent data for each subject treated with the study drug. The Investigator will 
make a ll safety assessments (AEs, vital signs, results from physical examinations, and laboratory tests) on 
an ongoing basis. The Investigator is responsible for all information collected on subjects enrolled in this 
study. All data collected during the course of this study must be reviewed and verified for completeness 
and accuracy by the Investigator. 
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Study personnel at each site will enter data from source documents corresponding to a subject's visit into 
the protocol-specific eCRF when the information corresponding to that visit is available. For all entries into 
the eCRF that are not source electronic data, the data entries must be supported by original source 
documentation (e.g., laboratory reports, medical records) maintained at the investigational site. 
If a subject is lost to follow-up, (i.e., fails to return for scheduled visits) every reasonable effort must be 
made to contact the subject's parent or guardian in order to determine why the subject failed to return. 
All actions taken in this regard will be documented and dated in the eCRF and source record. 
All documents will be stored safely in confidential conditions. On all trial-specific documents, other than 
the signed consent, the participant will be referred to by the trial participant number/code, not by name. 
13.2. 
Access to Data 
Direct access will be granted to authorised representatives from the Sponsor, host institution and the 
regulatory authorit ies to permit trial-related monitoring, audits, and inspections. 
13.3. 
Data Recording and Record Keeping 
An eCRF will be completed for each subject who is assigned a study number and signs and dates the 
studyapproved ICF. All trial data will be entered on eCRF, which is software for capturing and managing 
clinical trial data. The software supports Good Clinical Practice (GCP). It has an intuitive interface for 
enrolment, clinical data capture, validation, and query management. The software uses tools for data 
cleaning, clinical data management, site monitoring, and for overall system oversight, auditing, and 
reporting. The study infants will be identified by a unique trial specific number and/ or code in all 
databases. The name and any other identifying detail will NOT be included in any trial data electronic file. 
The investigator or a designee will be logging into the system and entering the data directly at the site. 
The entries made in the eCRF will be monitored by a Clinical Research Associate (CRA) for completeness 
and accuracy. Edit checks/ rules will be configured for identifying discrepancies. These discrepancies will 
be resolved by investigators or designee after logging into the system. If a correction is required for an 
eCRF data, the t ime and date stamps track the person entering or updating eCRF data and create an 
electronic audit trail. 
The investigator is required to electronica lly sign the eCRF at appropriate t ime intervals. The investigator's 
signature on the eCRF serves to certify that the data collected for each subject is accurate, complete and 
legible. A copy of the eCRF will remain at the study site at the completion of the study. 
14. 
STUDY MONITORING 
The trial will be conducted in accordance with the current approved protocol, ICH GCP, relevant 
regulations, and standard operating procedures. 
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The Sponsor's designees w ill monitor all aspects of the study carefully w ith respect to ICH GCPs and SOPs 
for compliance with applicable government regulations. The investigator is responsible for providing all 
study records, including eCRFs, source documents, etc., for review and inspection by the clinical monitor. 
eCRF will be periodically monitored and source verified against corresponding source documentation (e.g., 
office and clinical laboratory records) for each subject. Clinical monitors w ill evaluate periodically the 
progress of the study, including the verification of appropriate consent form procedures, review of drug 
accountability and study drug preparation procedures, adherence to dosing procedures, the investigator's 
adherence to the protocol, maintenance of records and reports, review of source documents for accuracy, 
completeness, and legibility, and review of study regulatory documents, including, but not limited to: study 
agreement, study insurance, study approval letters by the IRB/ IEC and the Regulatory Authority, site staff 
CV and financial statements, study forms, protocol signature page, etc. In addit ion, the monitor shall 
review completed eCRF and study documentation for accuracy and completeness, and protocol 
compliance. The monitor should assure that data captured in the eCRF is fully supported by the source 
documents. Clinical monitors will also ensure that all protocol requirements, applicable Food and Drug 
Administration (FDA) regulations (CFR Tit le 21 Parts 50, 56, and 312 and ICH Guidelines for GCP - E6), other 
requirements, and Investigator's obligations are being fulfilled. 
By signing this protocol, the Investigator grants permission to the Sponsor (or designee), and appropriate 
regulatory authorities to conduct on-site monitoring and/ or audit ing of all appropriate study 
documentation. 
Apart from assuming responsibility for the communication between the investigator and the Sponsor, the 
clinical monitor duties include: 
• 
On-site visits; and 
• 
Review of study documents and results. 
On-site monitoring visits include pre-study/qualification visits, initiation visits, interim monitoring visits, 
and a close-out visit at the end of the study. At the close of the study, the monitor w ill be required to make 
a final on-site visit to assure that all study data has been properly completed. 
Reports of on-site visits shall be made by the monitor and should include, as applicable, resolution of 
concerns and queries, completion of appropriate follow-up activit ies, completion of assigned tasks, and 
corrective actions. Monitoring visit follow -up letters will be sent to the site for filing and adherence. 
All data generated in the current clinical investigation will be managed according to relevant guidelines 
(e.g. GCP, 21 CFR Part 11). 
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15. 
ETHICAL AND REGULATORY CONSIDERATIONS 
15.1. 
Declaration of Helsinki 
This study w ill be conducted in accordance with the ethical principles that have their origin in the 
Declaration of Helsinki and that are consistent with the Good Clinical Practice and the applicable regulatory 
requirements. 
15.2. 
ICH Guidelines for Good Clinical Practice 
The Investigator will ensure that this trial is conducted in full conformity with relevant regulations and with 
the ICH Guidelines for Good Clinical Practice (CPMP/ ICH/ 135/ 95) July 1996. 
15.3. 
Approvals, Information on Study Infants, and Consent Form 
This trial will be initiated only after all required legal documentation has been reviewed and approved by 
the respective IRB / Independent Ethics Committee (IEC) and competent authority (CA) according to 
national and international regulations. The same applies for the implementation of changes introduced 
by amendments. Prior to an infant's participation in the trial, written informed consent must be obtained 
for each infant (by both parents and accepted legal representatives) according to ICH GCP and the 
regulatory and legal requirements of the participating country. Each signature must be personally dated 
by each signatory, and the informed consent form and any addit ional infant information form must be 
retained by the investigator as part of the trial records. A signed copy of the informed consent form and 
any addit ional infant information must be given to each infant's parents or the infant's legally accepted 
representative. 
The parents must be informed that his/ her personal trial-related data will be used by Nutrinia in 
accordance with the local data protection law. The level of disclosure must also be explained to the 
parents. 
15.4. 
Data Quality Assurance 
A quality assurance audit/ inspection of this trial may be conducted by the sponsor or sponsor's designees 
or by IRBs/ lECs or by regulatory authorities. The quality assurance auditor will have access to all medical 
records, the investigator's trial-related files and correspondence, and the informed consent 
documentation of this clinical trial. 
15.5. 
Participant Confidentiality, data disclosure and publication 
Subject medical information obtained as a result of this study is considered confidential. Disclosure to 
third parties other than those noted below is prohibited. All reports and communications relating to 
subjects and their parent(s) or guardians(s) in this study will identify all persons only by their initials and 
number. Medical information resulting from a subject's participation in this study may be given to the 
subject's personal physician or to the appropriate medical personnel responsible for the subject's 
welfare. Data generated as a result of this study are to be available for inspection on request by FDA or 
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other government regulatory agency auditors, the Sponsor, the Sponsor-assigned clinical monitor (or 
designee), and the IRB/ IEC. 
All laboratory specimens, evaluation forms, reports, and other records that leave the site will be 
identified by a coded number to maintain subject confidentiality. All records will be maintained in 
lockable file cabinets. All computer entry and networking programs will be identifiable only by coded 
numbers. Clinical information w ill not be released without w ritten permission from the subject's parent 
or guardian, except as necessary for monitoring by the IRB, the FDA, or representatives of the study 
Sponsor. 
Any information, inventions, or discoveries (whether patentable or not), innovations, suggestions, ideas, 
and reports, made or developed by an investigator as a result of conducting this study shall be promptly 
disclosed to the Sponsor and shall be the sole property of the Sponsor. The Investigator agrees, upon 
the Sponsor's request and at the Sponsor's expense, to execute such documents and to take such other 
actions, as the Sponsor deems necessary or appropriate, to obtain patents in the Sponsor's name 
covering any of the foregoing. 
The results of this study w ill be published under the direction of the Sponsor. Results will not be published 
w ithout prior review and approval by the Sponsor. 
15.6. 
Expenses and Benefits 
No complications are anticipated from feeding the infant with the study insulin-enriched oral nutrition. No 
evidence or scientific findings of long-term negative effects stemming from feeding preterm infants w ith 
the insulin-enriched nutrition have been noted. This is also true w hen administering higher concentrations 
of insulin than the quantity proposed in this trial. Nonetheless, the possibility of long-term effects on the 
creation of insulin antibodies or the prevention of diabetes cannot be ruled out. A study infant may 
experience a slight but insignificant drop in the blood sugar level. 
Should the trial show that insulin indeed speeds up the maturation of the digestive tract, a study infant 
treated w ith NTRA-2112 may reach full nutrit ion sooner than would have occurred had the infant not been 
in the trial. 
This would reduce the risks to preterm infants and may provide better growth and 
development. In addit ion, the infant w ill contribute to study a new medication that may help thousands 
of pre-term infants born each year and suffer from complications due to immature digestive system 
Nutrinia is responsible for managing the financing for the study. Nutrinia has signed a contract w ith the 
facilities where they will perform the trial w ith the study doctor. The participation of the infant in the 
study will not involve any costs and the infant's parent or guardian will not have to pay for the study drugs. 
16. 
RETENTION OF STUDY DOCUMENTS 
The Pl should retain records for all study infants, including eCRFs, all source documentation (containing 
evidence of study eligibility, history and physical findings, laboratory data, results of consultations, etc.) as 
well as IRB/IEC records and other regulatory documentation in a secure storage facility. The records should 
be accessible for inspection and copying by authorized authorities. 
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Essential documents must be retained for a minimum of 2 years after the final marketing approval in an 
ICH region or at least 2 years have elapsed since the discontinuation of clinical development of the 
investigational product. In addition, all medical records of the infant and other source documentation will 
be kept for the maximum time permitted by the hospital, institution, or medical practice. 
17. 
FINANCE AND INSURANCE 
17.1. 
Funding 
Financing of this study will be outlined in a separate document. 
17.2. 
Insurance 
Insurance of this study will be outlined in a separate document. 
The terms and condit ions of the insurance cover are made available to the investigator and the parents 
through documentation in the Investigator Site File. 
18. 
PUBLICATION POLICY 
The investigator contract describes the rights of the investigator and of the sponsor with regard to 
publication of the results of this trial. As a general rule, no trial results should be published prior to 
finalization of the Clinical Trial Report to regulatory authorit ies. 
The Principal Investigator will prepare a complete review of the study and abstracts for professional 
meetings. Published data must not compromise the objectives of the study or the confidentiality of the 
infants enrolled. 
19. 
REFERENCES 
1. 
Neu J. The Neonatal Gastrointest inal Tract: Developmental Anatomy, Physiology, and Clinical 
Implications. New Reviews. 2003;4(7). 
2. 
Neu J. Gastrointestinal development and meeting the nutritional needs of premature infants. Am 
J Clin Nutr. 2007;85(2):629S-34S. 
3. 
Senterre T. Practice of enteral nutrition in very low birth weight and extremely low birth weight 
infants. World Rev Nutr Diet. 2014;110:201-14. 
4. 
Shulman RJ. Oral insulin increases small intestinal mass and disaccharidase activity in the new born 
miniature pig. Pediatric research. 1990;28(2):171-5. Epub 1990/ 08/ 01. 
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5. 
Shulman RJ, Tivey DR, Sunitha I, Dudley MA, Henning SJ. Effect of oral insulin on lactase activity, 
mRNA, 
and posttranscriptional processing in the newborn pig. Journal of pediatric 
gastroenterology and nutrit ion. 1992;14(2):166-72. 
6. 
Visscher M, Narendran V. The Ontogeny of Skin. Advances in wound care. 2014;3(4):291-303. Epub 
2014/ 04/ 25. 
7. 
Buts JP, De Keyser N, Sokal EM, Marandi S. Oral insulin is biologically active on rat immature 
enterocytes. Journal of pediatric gastroenterology and nutrition. 1997;25(2):230-2. 
8. 
Shehadeh N, Gelertner L, Blazer S, Perlman R, Solovachik L, Etzioni A. Importance of insulin content 
in infant diet: suggestion for a new infant formula. Acta paediatrica. 2001;90(1):93-5. Epub 
2001/ 03/ 03. 
9. 
Shehadeh N, Khaesh-Goldberg E, Shamir R, Perlman R, Sujov P, Tamir A, et al. Insulin in human 
milk: postpartum changes and effect of gestational age. Archives of disease in childhood Fetal and 
neonatal edition. 2003;88(3):F214-6. Epub 2003/ 04/ 30. 
10. 
Corps AN, Brown KO. Stimulation of intestinal epithelial cell proliferation in culture by growth 
factors in human and ruminant mammary secretions. The Journal of endocrinology. 
1987;113(2):285-90. Epub 1987/ 05/ 01. 
11. 
Shulman RJ. Effect of enteral administration of insulin on intestinal development and feeding 
tolerance in preterm infants: a pilot study. Archives of disease in childhood Fetal and neonatal 
edition. 2002;86(2):F131-3. Epub 2002/ 03/08. 
12. 
Robins J. The control of confounding by intermediate variables. Statistics in medicine. 
1989;8(6):679-701. Epub 1989/ 06/ 01. 
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Clinical Trial Protocol: FIT-04 
Appendix B: Study Flow Diagram 
~TR,.\. 2112 
2000 µU/ml Insulin 
l 
Days 1-2&'di,charie. (da.ily basis) 
reeding, gastnc l'l.'Sidual glucose 
lc:,d, h ~ical ,mdAF SAf lrackinu. 
Day 28 discharge· 
Bkx1d l~b rcsl'i 
l 
3 Month Corrected AJc 1-oUow t p 
Phy~ical ex<1m, blood l.ib le1»b 
AE/SAC tracking 
! 
Up lo 24 Month CorrccrcdAgc Foll<1w L'p 
Body\, ei!!ht. lenJ!lh. Head circumference. 
Development assessments, Af/SAE 
Lrackinl! 
I 
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Nutrinia 
Version 7 dated 10 May 2017 
Parents informed consent fonn signing 
Screenine 
Randomization 
NTRA-2112 
400 µU/ml Insulin 
l 
Days 1-28 'discna11c: (daily ba,is) 
FeedtnJ!. ga!,tne re.iduat glucose 
level physical andAE-SAE tracking. 
l 
Day 28 'dii.cl1argc· 
Blood lab tests 
3 Moruh Corrocted.\J!e foUow t:p 
Physical exam, blood lab tests 
Af.JSAE lmd:ing 
! 
l p 1t1 2J Mo111h C"iim-ctcd Age Fnlkm Up 
Body weiiht lenJ!th. Head circwllfe1ence. 
De\-elt'pment MSe•srnents, AE. SAE 
tnicldnl! 
I 
• 
I StudyT.:nnirunion, End I 
CONFIDENTIAL 
Placebo rm 
l 
Days 1-2 'clisch~c· (Mily ootjs) 
F cedillf!,. J!IWl'iC residual, !l,fuC-O:.e 
level physical and AE.SAE lrncking. 
Day 28 tlli.chnrge. 
Dlood lab te-sts 
3 Mouth Com:cte dAge follow Up 
blood lab lc:~I;, 
uacking 
Phy:.ical exam, 
AE/SAE 
l 
Up to 24 Month C'o 
Body 1\·e~eht, lenitl1. 
rrcct«l Age Folio\, l'p 
Head d1cumference. 
essmenb,AEiS "-£ 
kin• 
Development RSS 
1rac 
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Appendix C: SAE Reporting Flow Chart 
...... • 
Version 7 dated 10 May 2017 
A£ observed I 
Is It serloui? j 
Nutrinia 
t 
L 
SAE 
-:;-
eGO<d, 11.ssesi and Rej)on to: 
• Sponsor within 24 hours (unrelated SAEs 
other than death within up to 48 houn) 
rd on Case Report 
ms/Medical Notes 
t 
r 
E.lrpecttd SAR 
Report as SAC above 
• IRB/IEC llCCording to loal regul.itions and <IS 
required by thP institution 
ts it refatt>d to study medicallon 
(possible/probable related}? 
r-
♦ :7 
SAE 
Report as SAE above 
Is it expected evt_nt (hstcd In 
lnvestlc.itor brodiure or study 
protocol at the same sp«ifioty 
al'ld seventy as observed)? 
.L 
SUSAR =i 
Record, Assess and Report to Sponsor 
within 24 hours 
L-
is It fatal or life threatenJng? 
' Report to: 
J 
• IRB/IEC_ acco,-d1ng to local r~ulatloru 
and as required by lhe 1ns1.11u110.n 
• Rl'g1.1l~tory Author•tv w,thin 7 days 
G
rtto: 
j 
8/IEC: ucording to local regulations 
nd as required by the 1nsmut1on 
l'lulatory Au1hotity within 15 dm 
AE: Adverse event 
SAE: Serious adverse event 
SAR: Serious adverse reaction 
SUSAR: Suspected unexpected serious adverse event 
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Appendix D: Fenton Preterm Growth Chart 
60 
60 
55 
55 
50 
50 
45 
40 
35 
6.5 
!!! 30 
6 
.!? 
i 2s 
t:: 
5.5 
Cl u 
20 
5 
15 
45 
4 
4 
ft 
E 
3.5 
3 5:? 
~ 
6 
3 
32 
a; 
_ 25 
25~ 
Ill 
E 
m j 
2 
2 
g_ 
t 1.s 
j 
J
'2013 
t.5 
1 
1 
0-5 
o,2 
24 
~ 28 
30 
32 
34 
www 'Cll',lllr, ,:a,tenbn 
36 
38 
40 
4? « 
46 
48 
50 0 
Date 
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60 
60 
.A,., 
55 
,,-· 
55 
50 
50 
45 
f 451 
".:l 
40 
C 
40,~ 
35 
6.5 
i;o 30 
6 
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) 2s 
5.5 
C: 
~ 
20 
5 
15 
4.5 
,4 
4 -; 
E 
3.5 
35~ :I 
~ 
3 
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m 
- 2.5 
25~ 
Ill 
E 
I!! E 
~ 
2 
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t 1 s 
I 
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0.5 
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24 
26 
28 
30 
32 
34 
36 
38 
40 
.si 
44 
46 
48 
50 
O.S.te-
Gestat,on:11 ag,e iweekl! 
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Appendix E: Expected Complications Related to Premature Birth 
While not all premature babies experience complications, being born too early can cause short-term and 
long-term health problems for preemies. Generally, the earlier a baby is born, the higher the risk of 
complications. Birth weight plays an important role, too. 
Some problems may be apparent at birth, while others may not develop until later. 
Short-term complications 
In the first weeks, the complications of premature birth may include: 
• 
Breathing problems. A premature baby may have trouble breathing due to an immature respiratory 
system. If the baby's lungs lack surfactant -
a substance that allows the lungs to expand -
he or she may 
develop respiratory distress syndrome because the lungs can't expand and contract normally. 
Preemies may also develop chronic lung disease known as bronchopulmonary dysplasia. In addition, some 
preemies experience prolonged pauses in their breathing, known as apnea. 
• 
Heart problems. The most common heart problems premature babies experience are patent ductus 
arteriosus (PDA) and low blood pressure (hypotension). PDA is a persistent opening between two major 
blood vessels leading from the heart. 
While this heart defect often closes on its own, left untreated it can cause too much blood to flow through 
the heart and cause heart failure as well as other complications. Low blood pressure may require 
adjustments in intravenous fluids, medicines and sometimes blood transfusions. 
• 
Brain problems. The earlier a baby is born, the greater the risk of bleeding in the brain, known as an 
intraventricular hemorrhage. Most hemorrhages are mild and resolve with little short-term impact. But 
some babies may have larger brain bleeding w hich causes permanent brain injury. 
Larger brain bleeds may lead to fluid accumulation in the brain (hydrocephalus) over a number of weeks. 
Some babies who develop hydrocephalus will require an operation to relieve the fluid accumulation. 
• 
Temperature control problems. Premature babies can lose body heat rapidly; they do nott have the 
stored body fat of a full-term infant and they cannot generate enough heat to counteract w hat's lost 
through the surface of their bodies. If body temperature dips too low, hypothermia can result . 
Hypothermia in a preemie can lead to breathing problems and low blood sugar levels. In addit ion, a 
preemie may use up all of the energy gained from feedings just to stay warm, not to grow bigger. That is 
w hy smaller preemies require additional heat from a warmer or an incubator until they are larger and able 
to maintain body temperature w ithout assistance. 
• 
Gastrointestinal problems. Preemies are more likely to have immature gastrointestinal systems, leaving 
them predisposed to complications such as necrotizing enterocolitis (NEC). 
This potentially serious 
condition, in which the cells lining the bowel wall are injured, can occur in premature babies after they 
start feeding. Premature babies w ho receive only breast milk have a much lower risk of developing NEC. 
• 
Blood problems. Preemies are at risk of blood problems such as anemia and infant jaundice. Anemia is a 
common condition in which the body does not have enough red blood cells. While all newborns experience 
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a slow drop in red blood cell count during the first months of life, the decrease may be greater in preemies, 
especially if the baby has a lot of blood taken for lab tests. 
Infant jaundice is a yellow discoloration in a new born baby's skin and eyes that occurs because the baby's 
blood contains an excess of a yellow-colored pigment from the liver or red blood cells (bilirubin). 
• 
Metabolism problems. Premature babies often have problems with their metabolism. Some preemies 
may develop an abnormally low level of blood sugar (hypoglycemia). This can happen because preemies 
typically have smaller stores of glycogen (stored glucose) than do full-term babies and because preemies' 
immature livers have trouble converting stored glycogen into glucose. 
• 
Immune system problems. An underdeveloped immune system, common in premature babies, can lead 
to infection. Infection in a premature baby can quickly spread to the bloodstream causing sepsis, a 
lifethreatening complication. 
Long-term complications 
In the long term, premature birth may lead to these complications: 
• 
Cerebral palsy. Cerebral palsy is a disorder of movement, muscle tone or posture that can be caused by 
infect ion, inadequate blood flow or injury to a preemie's developing brain either during pregnancy or w hile 
the baby is still young and immature. 
• 
Impaired cognitive skills. Premature babies are more likely to lag behind their full-term counterparts on 
various developmental milestones. Upon school age, a child w ho w as born prematurely might be more 
likely to have learning disabilities. 
• 
Vision problems. Premature infants may develop retinopathy of prematurity, a disease that occurs when 
blood vessels swell and overgrow in the light-sensit ive layer of nerves at the back of the eye (retina). 
Sometimes the abnormal retinal vessels gradually scar the retina, pulling it out of position. When the 
retina is pulled away from the back of the eye, it is called retinal detachment, a condition that, if 
undetected, can impair vision and cause blindness. 
• 
Hearing problems. Premature babies are at increased risk of some degree of hearing loss. All babies will 
have their hearing checked before going home. 
• 
Dental problems. Preemies w ho have been critically ill are at increased risk of developing dental problems, 
such as delayed tooth eruption, tooth discoloration and improperly aligned teeth. 
• 
Behavioral and psychological problems. Children who experienced premature birth may be more likely 
than 
full-term 
infants 
to 
have 
certain 
behavioral 
or 
psychological 
problems, 
such 
as 
attentiondeficit/ hyperactivity disorder (ADHD). However, more recent research suggests that -
at least 
for late preterm babies -
the risk of ADHD may be the same as it is for children w ho were born at full 
term. 
• 
Chronic health issues. Premature babies are more likely to have chronic health issues -
some of w hich 
may require hospital care -
than are full-term infants. Infections, asthma and feeding problems are more 
likely to develop or persist. Premature infants are also at increased risk of sudden infant death syndrome 
(SIDS). 
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Appendix F: Example for TBV volume 
TBV is considered based on the following table: 
Subjects 
Total Blood 
Maximum in 30 day 
Weight 
Volume 
Maximum in 24 hours 
period 
(Kg) 
(ml ) 
(3 m l / kg) 
(5% ofTBV) 
1 
100 
3 
5 
2 
200 
6 
10 
3 
240 
9 
12 
4 
320 
12 
16 
5 
400 
15 
20 
6 
480 
18 
24 
7 
560 
21 
28 
8 
640 
24 
32 
9 
720 
27 
36 
10 
800 
30 
40 
11-15 
880-1200 
33-45 
44-60 
16-20 
1280-1600 
48-60 
64-80 
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