Milrinone in Congenital Diaphragmatic Hernia
Phase: PHASE2
Conditions: Congenital Diaphragmatic Hernia, Persistent Pulmonary Hypertension of the Newborn, Hypoxemic Respiratory Failure, Pulmonary Hypoplasia
Sponsor: NICHD Neonatal Research Network

Version 5.0 
Milrinone in Congenital Diaphragmatic Hernia 
 
ClinicalTrials.gov number: 
NCT02951130 
 
 
Lead Study Investigator(s): 
Satyan Lakshminrusimha, University of California Davis 
 
Vice-Chair: 
 
 
Martin Keszler, Brown University 
 
Subcommittee Members:  
Haresh Kirpalani, Children’s Hospital of Philadelphia 
Patricia Chess, University of Rochester 
Namasivayam Ambalavanan, University of Alabama at 
Birmingham 
Krisa van Meurs, Stanford University 
Maria V. Fraga, Children’s Hospital of Philadelphia 
Leif Nelin, Nationwide Children’s Hospital 
Michael Cotten, Duke University 
Jonathan Klein, University of Iowa 
Brad Yoder, University of Utah 
Aasma Chaudhary, Coordinator, Children’s Hospital of 
Philadelphia 
Jonathan Snyder, Coordinator, Children’s Hospital of Philadelphia 
Carrie Rau, Coordinator, University of Utah 
Marie Gantz, RTI 
Abhik Das, RTI and 
Michele Walsh, NIH/NICHD 
Surgical consultants: Holly L. Hedrick, Children’s Hospital of 
Philadelphia and Kevin P. Lally, UT, Houston. 
 
Protocol Version Date: 
March 2, 2017 
            Revised: 
February 21, 2018 
 
 
 
March 28, 2019 
 
 
 
July 23, 2020 
 
 
 
December 16, 2021 
 
 
 

 
 
Contents 
Section 1. 
Abstract ................................................................................................................... 1 
Section 2. 
Statement of Problem............................................................................................. 9 
2.1. 
Hypothesis................................................................................................... 9 
2.2. 
Specific Aims ............................................................................................. 10 
2.3. 
Background ............................................................................................... 10 
2.3.1. Congenital Diaphragmatic Hernia ................................................. 10 
2.3.2. Etiology of Pulmonary Hypertension Associated with CDH ......... 13 
2.3.3. Milrinone ....................................................................................... 14 
2.4. 
Justification for the Study ......................................................................... 21 
Section 3. 
Study Design.......................................................................................................... 24 
3.1. 
Primary Outcome ...................................................................................... 24 
3.2. 
Secondary Outcomes ................................................................................ 24 
3.3. 
Study Intervention .................................................................................... 26 
3.4. 
Blinding/Masking ...................................................................................... 26 
3.5. 
Potential Risks and Benefits to Subjects ................................................... 27 
Section 4. 
Methods ................................................................................................................ 30 
4.1. 
Study Population ....................................................................................... 30 
4.1.1. Inclusion Criteria ........................................................................... 30 
4.1.2. Exclusion Criteria........................................................................... 30 
4.2. 
Detailed Study Procedures........................................................................ 33 
4.2.1. Screening ....................................................................................... 33 
4.2.2. Consent Procedures ...................................................................... 33 
4.2.3. Randomization Procedures ........................................................... 34 
4.2.4. Stratification:................................................................................. 35 
4.2.5 In-hospital Procedures .................................................................. 35 
4.2.6 Post-hospital Procedures .............................................................. 42 
4.2.7 Additional Follow-up Examinations and/or Questionnaires ........ 42 
Section 5. 
Analytical Plan ....................................................................................................... 43 
5.1 
Sample Size and Power Estimates ............................................................ 43 
5.2 
Available Population ................................................................................. 44 
5.3 
Projected recruitment time ...................................................................... 45 
5.4 
Statistical Analysis Plan ............................................................................. 47 
5.5 
Data Monitoring Plan ................................................................................ 47 
5.5.1 Reporting Adverse Events ............................................................. 48 
5.5.2 Potential Adverse Events .............................................................. 49 
5.5.3 Interim Monitoring Plan and Stopping Rules................................ 49 
Section 6. 
References ............................................................................................................ 52 

 
 
1 
SECTION 1. 
ABSTRACT 
Introduction: Infants with congenital diaphragmatic hernia (CDH) usually have pulmonary 
hypoplasia and persistent pulmonary hypertension of the newborn (PPHN) leading to 
hypoxemic respiratory failure (HRF) that is often associated with cardiac dysfunction. 
Pulmonary hypertension associated with CDH is frequently resistant to conventional vasodilator 
therapy including inhaled nitric oxide (iNO). Increased pulmonary vascular resistance (PVR) can 
lead to right ventricular overload and dysfunction (Patel 2012, James, Corcoran et al. 2015). In 
patients with CDH, left ventricular dysfunction, either caused by right ventricular overload or a 
relative underdevelopment of the left ventricle, is associated with poor prognosis. Right 
ventricular dysfunction in CDH is also associated with poor prognosis (Moenkemeyer and Patel 
2014). Milrinone is an intravenous inotrope and lusitrope (enhances cardiac systolic contraction 
and diastolic relaxation respectively) with pulmonary vasodilator properties and has been 
shown anecdotally to improve oxygenation in PPHN (Bassler, Choong et al. 2006, McNamara, 
Laique et al. 2006, Bassler, Kreutzer et al. 2010, McNamara, Shivananda et al. 2012). Milrinone 
is commonly used during the management of CDH although no randomized trials have been 
performed to test its efficacy. Thirty percent of infants with CDH in the Children’s Hospital 
Neonatal Database (CHND) (Grover, Murthy et al. 2015) and 22% of late-preterm and term 
infants with CDH in the Pediatrix database (Malowitz, Hornik et al. 2015) received milrinone. In 
the recently published VICI trial, 84% of patients with CDH received a vasoactive medication. 
(Snoek, Capolupo et al. 2016) 
 
Objective: This is a Phase II pilot trial to determine if milrinone infusion in neonates ≥ 36 weeks’ 
postmenstrual age (PMA) at birth with CDH would lead to an increase in PaO2 with a 
corresponding decrease in OI (or OSI) by itself or in conjunction with other pulmonary 
vasodilators such as iNO at 24 h post-infusion. (Note: oxygenation index (OI), = Mean airway 
pressure x FiO2 x 100 ÷ PaO2 and oxygen saturation index (OSI) = Mean airway pressure x FiO2 x 
100 ÷ preductal SpO2). 
As secondary objectives, we will determine if milrinone improves oxygenation at 48 h and 72 h 
post-infusion, reduces right ventricular pressures on echocardiogram, and alters the risk of 
systemic hypotension, arrhythmias, intracranial hemorrhage, need for extracorporeal 
membrane oxygenation (ECMO), and chronic lung disease (CLD, defined as oxygen need at 28 d 
of postnatal age). Finally, we will also evaluate the infant’s medical (pulmonary and nutritional) 
status at discharge and conduct a phone questionnaire at 4, 8, and 12 months of age. 
 
Study Design: Double-blind randomized controlled pilot trial with 1:1 (treatment: control) 
randomization. 

 
 
2 
Eligibility criteria: 
Infants are eligible if they meet all of the following criteria: 
(i) ≥ 36 0/7 weeks postmenstrual age (PMA) at birth by best obstetric estimate AND birth 
weight of ≥ 2000g  
(ii) postnatal age ≤7 days (168 hours of age, including post-operative infants with HRF) 
(iii) invasive mechanical ventilation (defined as ventilation with an endotracheal tube) and  
(iv) one arterial blood gas with an OI ≥ 10 (after tracheal tube obstruction, pneumothorax 
and other easily resolvable mechanical causes for increased OI are ruled out) on the 
most recent arterial blood gas within 12 hours prior to the time of randomization. 
(v)  if an arterial blood gas is not available at the time of randomization, a preductal OSI of ≥ 
5 can be used as an inclusion criterion instead of OI ≥ 10; (the OSI should be based on 
the most recent preductal pulse oximetry recording and must be within 12 hours of 
randomization) 
(vi) postnatal blood gas with PCO2 ≤ 80 mmHg (arterial, capillary or venous blood gas) on 
the most recent blood gas sample obtained within 12 hours prior to randomization 
Note: Criteria (iv) to (vi) must be met at the most recent analysis within 12 hours prior to 
randomization. 
 
Stratification: Patients will be stratified based on severity of HRF using the prediction formula 
(PaO2/FiO2 ratio – PaCO2 value) at the time of randomization. (Park, Lee et al. 2013) Patients 
with prediction value ≥ 0 will be considered as “moderate” and infants with a value of < 0 as 
“severe” HRF.  If no arterial blood gas is available prior to randomization, an oxygen saturation 
index (OSI – see below) of 5 to 10 is considered “moderate” HRF and > 10 is considered 
“severe” HRF.   
In addition, the following markers of disease severity will be recorded if available in the medical 
chart (but not used for stratification): 
(a) Prenatal  
a. observed to expected lung to head ratio – O/E LHR, by antenatal ultrasound 
b. position of the liver,  
c. observed to expected fetal total lung volume (O/E FTLV) assessment by fetal MRI 
(Ruano, Lazar et al. 2014) (Kastenholz, Weis et al. 2016),  
(b) Postnatal  
a. oxygenation index (OI), = Mean airway pressure x FiO2 x 100 ÷ PaO2 
b. oxygen saturation index (OSI) = Mean airway pressure x FiO2 x 100 ÷ preductal SpO2, 
(Rawat, Chandrasekharan et al. 2015) 
c. evidence of pulmonary hypertension as determined by echocardiogram: 
i. velocity of the tricuspid regurgitation jet – if present,  
ii. the position of the inter-ventricular septum and  

 
 
3 
iii. direction of shunt at the patent foramen ovale – PFO and patent ductus 
arteriosus – PDA level  
(c) Intraoperative defect size (Congenital Diaphragmatic Hernia Study, Lally et al. 2007).  
Exclusion Criteria:  
Infants are ineligible if they meet any of the following criteria: 
• known hypertrophic cardiomyopathy  
o Note 1: infants of diabetic mothers with asymmetric septal hypertrophy can be 
included as long as there is no evidence of obstruction to left ventricular outflow 
tract on echocardiogram, 
o Note 2: infants with other acyanotic congenital heart disease (CHD) and CDH 
may be included in the study and will be a predetermined subgroup for analysis) 
• cyanotic CHD – transposition of great arteries (TGA), total anomalous pulmonary venous 
return (TAPVR), partial anomalous pulmonary venous return (PAPVR), truncus arteriosus 
(TA), tetralogy of Fallot (TOF), single ventricle physiology – hypoplastic left heart 
syndrome (HLHS), tricuspid atresia, critical pulmonic stenosis or atresia etc., 
• enrolled in conflicting clinical trials (such as a randomized controlled blinded trial of 
another pulmonary vasodilator therapy); Note: mothers enrolled in fetal tracheal 
occlusion studies such as FETO may be enrolled if permitted by investigators of the fetal 
tracheal occlusion study; More information about FETO can be found at 
http://www.chop.edu/centers-programs/center-fetal-diagnosis-and-
treatment/fetoscopic-endoluminal-tracheal-occlusion-feto or 
http://childrens.memorialhermann.org/FETO-trial/ [FETO refers to fetoscopic 
endoluminal tracheal occlusion and involves occlusion of fetal trachea with a balloon 
device at mid-gestation and subsequent removal in later gestation] 
• infants with bilateral CDH  
o Note 3: infants with anterior and central defects are included in the study 
• associated abnormalities of the trachea or esophagus (trachea-esophageal fistula, 
esophageal atresia, laryngeal web, tracheal agenesis) 
• renal dysfunction (with serum creatinine > 2 mg/dL not due to maternal factors) or 
oligohydramnios associated with renal dysfunction at randomization; renal dysfunction 
may be secondary to renal anomalies or medical conditions such as acute tubular 
necrosis 
• systemic hypotension (mean blood pressure < 35 mm Hg for at least 2 h with a 
vasoactive inotrope score of > 30) 
• decision is made to provide comfort/ palliative care and not full treatment 
• Known intracranial bleed (including the following findings on the cranial ultrasound) 
o Parenchymal hemorrhage – including blood in the cerebral parenchyma, 
cerebellar parenchyma or basal ganglia 

Revised July 23, 2020; December 16, 2021 
4 
o Blood/echodensity in the ventricle with distension of the ventricle 
o Midline shift secondary to mass effect from an intracranial hemorrhage 
• thrombocytopenia (platelet count < 80,000/mm3) despite blood product administration 
on the most recent blood draw prior to randomization 
• coagulopathy (PT INR > 1.7) despite blood product administration on the most recent 
blood draw (if checked – there is no reason to check PT for the purpose of this study) 
• aneuploidy associated with short life span (such as trisomy 13 or 18) will not be included 
in the study (infants with trisomy 21 can be included in the study) 
• use of milrinone infusion prior to randomization (the use of other inhaled pulmonary 
vasodilators such as iNO, inhaled epoprosternol, inhaled treprostinil, inhaled PGE1 and 
oral such as endothelin receptor antagonists is permitted – Note: it is unlikely to be on 
oral pulmonary vasodilators early in the course of CDH) 
• ongoing therapy with parenteral (intravenous or subcutaneous) pulmonary vasodilators 
such as IV/SQ prostacyclin analogs (Epoprostenol – Flolan® or Treprostinil – 
Remodulin®) or IV phosphodiesterase 5 inhibitors (sildenafil – Revatio®) at the time of 
randomization. Administration of IPGE1 is not an exclusion criteria.  In addition, 
initiation of therapy with these two classes of parenteral medications (except IPGE1) 
during the first 24 hours of study drug initiation is not permitted and will be considered 
a protocol deviation. The risk of systemic hypotension is high during the first 24 hours of 
study-drug (milrinone) infusion and hence parenteral administration of other pulmonary 
vasodilators is avoided to minimize risk of hypotension. 
• Subjects already on ECMO or patients who are being actively considered for ECMO by 
the neonatal or surgical team 
• Infants with hypoxic-ischemic encephalopathy (HIE) undergoing therapeutic 
hypothermia 
• attending (neonatal, critical care or surgical) refusal for participation in the trial 
(including concern about presence of hemodynamic instability) 
 
Study Intervention/Methods: An initial cranial ultrasound is obtained prior to initiation of study 
drug or within 4 hours of commencement of the study drug. A second cranial ultrasound is 
obtained preferably within 24 hours (maximum - within 96 hours) of completion of the study 
drug. Both these cranial ultrasounds are covered by the study budget. Additional head imaging 
may be performed based on clinical indications (but are not covered by the study budget). 
An echocardiogram, if clinically indicated, will preferably be obtained prior to (or within 6 hours 
of) initiation of the study drug. Infants with CDH will be randomized to receive a milrinone 
infusion at 0.33µg/kg/min or equal volume of placebo (D5W) infusion. The dose of the study 
drug will be increased to 0.66 µg/kg/min 2 to 4 hours after initiation of study drug if there is no 
evidence of hypotension (as defined as mean blood pressure < 35 mmHg and a vasoactive 

 
 
5 
inotrope score > 30; Vasoactive Inotrope score = dose of dopamine in µg/kg/min + dose of 
dobutamine in µg/kg/min + 100 X epinephrine dose in µg/kg/min + 100 X norepinephrine dose 
in µg/kg/min + 100 X phenylephrine dose in µg/kg/min + 10000 x vasopressin dose in U/kg/min) 
two hours after initiation of study drug. Infusion will be continued until the OI decreases to < 7 
(or OSI < 3.5 if no arterial blood gas is available).  The study drug will be continued during 
surgery and if the patient requires either veno-arterial or veno-venous extracorporeal 
membrane oxygenation (VV-ECMO or VA-ECMO) if permitted by the clinical team. The 
maximum duration of study drug infusion is 72 h.  After 70 h (if the patient is on 0.66 µg/kg/min 
or 72h if the patient is on 0.33 µg/kg/min) of study drug infusion (or earlier if two consecutive 
OIs at least one hour apart are < 7 or OSIs < 3.5 if no arterial blood gas is available), the infusion 
rate of the study drug is weaned and subsequently discontinued. Data from a maximum of 4 
echocardiograms, if performed for clinical indications will be recorded, (a) first 
echocardiogram, preferably prior to onset of study drug or within 6 hours of initiation of study 
drug, (b) second echocardiogram, 6 – 36 h after initiation of study medication (c) third 
echocardiogram, 36 h after initiation of study medication but prior to completion or 
discontinuation of study-drug and (d) first echocardiogram after completion of the study drug.  
 
Infusion of the study drug will be stopped if the mean blood pressure decreases < 35 mmHg 
and by > 20 mmHg (from pre-study drug mean blood pressure) after initiation of study drug and 
remains low for 2 hours despite treatment with > 40 ml/kg/24h of fluids and vasoactive 
medications (with a vasoactive inotrope score of > 30). Once the study drug is discontinued for 
improvement in oxygenation or a decrease in systemic blood pressure, it will not be restarted 
even if the condition leading to discontinuation changes (such as change in oxygenation or 
blood pressure). However, clinical providers can initiate open-label milrinone at their 
discretion. Study drug will also be stopped in the presence of renal dysfunction and/or 
development of a large intracranial (intraventricular with distension of the ventricle or 
parenchymal) bleed/echodensity. 
 
Primary Outcome:  
The primary outcome is the oxygenation response, as determined by change in OI (or OSI if no 
arterial blood gas is available) at 24h after initiation of study drug. In patients that require 
ECMO or die prior to completion of 24h from the initiation of the study drug, the last OI (or OSI 
if no arterial blood gas is available) prior to initiation of ECMO or death will be used for analysis. 
In patients without an arterial line (or if the line is lost), oxygen saturation index (OSI) will be 
calculated using a preductal oximeter. (Rawat, Chandrasekharan et al. 2015) 
 
 
 

 
 
6 
Secondary outcomes:  
(i) Oxygenation response at 24 h after initiation of study drug assigning a minimum OI of 40 
or OSI of 20 for subjects that need ECMO or die after initiation of study drug infusion 
but prior to 24h of study-drug infusion. In this analysis if the patient’s OI is 30 (or OSI of 
15) and is cannulated for ECMO due to hemodynamic instability, he/she will be assigned 
an OI of 40 (or OSI of 20). However, if the OI prior to ECMO is 47 (i.e., > 40), the higher 
number (47) will be used for analysis of this secondary outcome. 
(ii) Oxygenation index at 48 and 72 h after initiation of study drug (or OI/OSI at the time of 
initiation of ECMO or immediately prior to death, for infants placed on ECMO or died 
before these time points), 
(iii) Change in echocardiographic findings – velocity of tricuspid regurgitation, left 
ventricular ejection fraction, position of the interventricular septum and direction of 
shunt at the PDA and PFO level – prior to and 24-72h after starting the study 
medication.  This outcome will be available only for those infants who have a pre-study 
drug echocardiogram and a second echocardiogram between 24-72 h after initiation of 
study drug. These data will be extracted from echocardiograms performed for clinical 
indications. 
(iv) Vasoactive Inotrope score and systemic blood pressure 
(v) Area under the curve for inspired oxygen after initiation of the study drug over the first 
72 hours of study-drug infusion (or prior to ECMO or death, whichever is earlier) (Note: 
inspired oxygen and ventilator data from 4 time points per day – every 6 hours will be 
recorded to calculate area under the curve),  
(vi) If subsequent to the study drug, any additional inotrope or pulmonary vasodilator is 
used (such as iNO), we will evaluate the oxygenation response to these agents. If 
inotropes or vasodilators were used prior to the initiation of study drug, similar values 
will be recorded. The OI or OSI and PaO2/ FiO2 ratio prior to and after initiation of the 
inotrope / vasodilator are recorded (these data are recorded at 6 hour intervals; the 
date and time of initiation of individual inotropes and vasodilators is recorded). The 
change in OI or OSI and PaO2/ FiO2 ratio in response to these agents is evaluated as a 
continuous variable and arbitrarily classified into responders, partial responders and 
non-responders similar to prior trials (NINOs 1997, 1997). 
a.  complete response is defined as an increase in PaO2/ FiO2 ratio > 20 mmHg from 
baseline,  
b. partial response is an increase in PaO2/ FiO2 ratio of 10 to 20 mmHg from 
baseline, 
c. no response is defined as an increase of < 10 mmHg (or a decrease) in PaO2/ FiO2 
ratio from baseline,  

 
 
7 
d. the site of sampling (preductal vs. postductal) is also recorded. (Gien and Kinsella 
2016); right radial and ulnar arterial lines/sticks will be considered preductal; Left 
radial and ulnar arterial samples are usually preductal but can occasionally be 
postductal; umbilical arterial lines and posterior tibial lines (both sides) are 
always postductal. 
e. in patients without arterial access, an OSI (oxygen saturation index) will be used 
(vii) 
Supplemental oxygen at 28 d, and 56 d (or discharge, whichever comes earlier) 
from the hospital – primary institution or secondary institution to which patient was 
transferred. The use of supplemental oxygen at 28 d will be used to calculate the 
incidence of chronic lung disease. Chronic lung disease severity will be classified similar 
to the BPD classification in preterm infants at > 32 week gestation (Jobe and Bancalari 
2001). Supplemental oxygen use should be continuous. Intermittent supplemental 
oxygen given only during feedings or for spells administered for < 60 minutes and if the 
infant is not receiving oxygen at any other time during the day will not be considered as 
“supplemental oxygen”. 
a. Time point of assessment:  28 d, 56 d postnatal age or discharge to home 
whichever comes first.  
b. Mild CLD: treatment with oxygen > 21% oxygen for at least 28 days but breathing 
room air by 56 days’ postnatal age or discharge to home whichever comes first. 
c. Moderate CLD: need for > 21% but < 30% oxygen at 56 days postnatal age or 
discharge to home whichever comes first. 
d. Severe CLD: need for ≥ 30% oxygen and/or positive pressure (high-flow nasal 
cannula – defined for the purpose of this study as > 2 LPM, non-invasive 
ventilation or nasal intermittent positive pressure ventilation – NIV or NIPPV, 
CPAP, or positive pressure ventilation) at 56 days’ postnatal age or discharge 
whichever comes first. 
(viii) 
Survival to discharge (or day 120, whichever comes earlier) without ECMO and 
(ix) Clinical status – pulmonary (use of supplemental oxygen or respiratory medications – 
pulmonary vasodilators (sildenafil, bosentan etc.,), diuretics, methylxanthines, steroids, 
inhaled or nebulized steroids or bronchodilators) and nutritional (weight, length, head 
circumference, use of anti-reflux and prokinetic medications) at discharge from the 
hospital. Subsequently, a phone survey will be conducted to record the pulmonary and 
nutritional status of the subjects at 4, 8, and 12 months of age.  
(x) Feasibility to perform a definitive trial (primary outcome – improvement in survival 
without ECMO) and safety (incidence of systemic hypotension, intracranial bleeding and 
arrhythmias) 
 

 
 
8 
Conclusion: Congenital diaphragmatic hernia is an orphan disease with high mortality and few 
randomized, masked clinical trials evaluating postnatal management. Intravenous milrinone is a 
commonly used medication in neonatal and pediatric intensive care units and is currently used 
in 17% of patients with CDH within the NRN institutions, 22% of units in the Pediatrix network 
and 30% of units in the CHND network.  This pilot will provide data and enable further studies 
evaluating the efficacy of pulmonary vasodilator therapy in CDH.

 
9 
SECTION 2. 
STATEMENT OF PROBLEM 
2.1. 
HYPOTHESIS  
 
The overall goal is to determine whether intravenous administration of milrinone to newborn 
infants ≥ 36 weeks’ gestational age at birth with congenital diaphragmatic hernia (CDH) with an 
oxygenation index (OI) of ≥ 10 or an oxygenation saturation index (OSI) ≥ 5 will increase survival 
without extracorporeal membrane 
oxygenation (ECMO) by day 120 or 
discharge home (whichever comes 
first).  The goal of evaluating a 
decrease in the incidence of death or 
ECMO would need to be tested in a 
large (possibly international or NRN 
and non-NRN centers in the US), 
randomized, controlled clinical trial.  
However, before a large randomized 
trial is performed, a study to 
evaluate feasibility, short-term 
efficacy and safety is required.  
 
Our primary hypothesis for the 
current pilot is that milrinone 
infusion will lead to an increase in 
PaO2, with a corresponding decrease 
in OI (or OSI) and changes in 
echocardiographic markers of 
pulmonary hypertension, either by 
itself or in conjunction with other 
pulmonary vasodilators such as 
inhaled nitric oxide (iNO) at 24 h 
post-infusion (efficacy outcome). We 
also hypothesize that milrinone will 
not increase the risk of systemic 
hypotension, arrhythmias, 
intracranial hemorrhage, need for 
ECMO, chronic lung disease (CLD, 

 
10 
defined as oxygen need at 28 d of postnatal age), or oxygen need at discharge from the hospital 
or at day 120, whichever is earlier (safety outcomes). 
 
2.2. 
SPECIFIC AIMS 
 
Specific aim #1 - Efficacy: To determine the acute changes in oxygenation and 
echocardiography during treatment with IV milrinone (improvement in OI/OSI and PaO2 at 24 
hours from baseline and changes in right ventricular pressure and function at 24 – 72 h from 
baseline) 
 
Specific aim #2 - Safety:  To determine the safety of IV milrinone treatment by comparing the 
incidence of serious adverse events (severe hypotension, bleeding -  intracranial and 
extracranial hemorrhage and arrhythmias). 
 
Specific aim #3 - Outcome: To determine the infant’s status (pulmonary and nutritional) at 
discharge and conduct a series of telephonic surveys at 4, 8 and 12 months of postnatal age  to 
assess the impact of baseline characteristics (gender, gestational age at birth, mode of delivery, 
birth weight, time of diagnosis – antenatal vs. postnatal), study intervention and other 
therapies and interventions on infant’s status. 
 
Specific aim #4 - Feasibility:  To derive preliminary estimates of the incidence of survival 
without ECMO in the control and IV milrinone treatment groups and to demonstrate the 
feasibility of conducting a large randomized controlled clinical trial. 
 
2.3. 
BACKGROUND  
 
2.3.1. Congenital Diaphragmatic Hernia 
 
Congenital diaphragmatic hernia (CDH) is one of the common serious congenital anomalies 
managed in the neonatal intensive care unit (NICU) (Yoder, Lally et al. 2012). Despite many 
technological advances over the past two decades, including high frequency ventilation, iNO, 
surfactant replacement therapy and ECMO, CDH presenting in the neonatal period continues to 
be associated with relatively high rates of morbidity and mortality (28-30%)(Keller 2012, Yoder, 
Lally et al. 2012) (Table 1). Survival of infants at tertiary care centers automatically selects for 
patients who survive birth, resuscitation, and transport from an outside facility, and therefore 
likely underestimates the true hidden mortality associated with CDH. The major underlying 
pathophysiology in such infants appears to be a combination of lung immaturity, hypoplasia, 
and persistent pulmonary hypertension of the newborn (PPHN), which may be further 

 
11 
aggravated by left ventricular underdevelopment (Schwartz, Vermilion et al. 1994, Irish, 
Karamanoukian et al. 1996, Aggarwal, Stockman et al. 2011, Menon, Tani et al. 2012) (figure 1). 
Between 7/2008 and 6/2013, CDH was the diagnosis associated with the highest mortality 
among patients requiring ECMO for neonatal respiratory indications (table 1 and 2). Infants 
with CDH have prolonged length of stay in the NICU compared to many other congenital 
anomalies including critical congenital heart defects (table 1). 
 
Table 1. Survival and length of stay for babies with CDH and severe congenital heart disease 
cared in hospitals affiliated with Children’s Hospital Neonatal Database (CHND) between June 
2010 and March 2013 
Condition 
Discharge 
outcome 
Number 
Average length 
of stay 
Median length 
of stay 
Congenital 
diaphragmatic 
hernia (CDH) 
Survival  
341 (68%) 
52 d 
37 d 
Death 
160 (32%) 
22 d 
16 d 
Congenital heart 
disease (life 
threatening) 
Survival 
94 (73%) 
24 d 
16.5 d 
Death 
35 (27%) 
14 d 
7 d 
 
Table 2. Neonatal Respiratory ECMO Runs by Diagnosis (July 2008 – June 2013)  
                Data from ELSO registry – date of access July 01, 2013 
Diagnosis 
Total Runs (% 
total) 
Survived 
% Survived 
Congenital diaphragmatic hernia (CDH) 
1263 (29.8%) 
625 
49.5% 
Meconium aspiration syndrome (MAS) 
1069 (25.3%) 
1002 
93.7% 
Persistent pulmonary hypertension of the 
newborn (PPHN/PFC) 
896 (21.1%) 
677 
75.6% 
Respiratory distress syndrome (RDS) 
80 (1.9%) 
65 
81.3% 
Sepsis 
248 (5.9%) 
141 
56.9% 
Pneumonia 
53 (1.3%) 
29 
54.7% 
Air-leak syndrome 
11 (0.3%) 
7 
63.6% 
Others 
612 (14.4%) 
329 
53.8% 
Total 
4232 
2875 
67.9% 
 
In spite of such high mortality, only two randomized controlled trials (NINOS CDH pilot) 
targeting treatment of PPHN associated with CDH with iNO has been published to date (1997). 
This study failed to demonstrate any benefit of iNO; in fact, the need for ECMO was significantly 
increased in iNO treated infants. A second trial (VICI) evaluating high frequency oscillation vs. 

 
12 
conventional ventilation in Europe was published in 2016 (table 3) (Snoek, Capolupo et al. 
2014) (Snoek, Capolupo et al. 2016). The overall mortality by one year of postnatal age was 27% 
in this trial. This trial showed some benefits in the conventional ventilation arm compared to 
HFV but was stopped prior to completion of the expected sample size. 
 
Table 3. Morbidity and mortality in CDH associated with initial mode of ventilation (VICI trial) 
(Snoek, Capolupo et al. 2014) (Snoek, Capolupo et al. 2016) 
 
Variables: corrected for center  
(results are presented as n (%) or median 
(IQR) 
HFO (n = 80) 
CMV (n = 91) 
p-value 
Length of ventilation (days) 
13 (8–23) 
10 (6–18) 
0.03 
Severity CLD  
No CLD 
Mild CLD 
Moderate CLD 
Severe CLD 
Died 
37 (46.3%) 
7 (8.8%) 
2 (2.5%) 
9 (11.3%) 
25 (31.3%) 
50 (54.9%) 
13 (14.3%) 
1 (1.1%) 
6 (6.6%) 
21 (23.1%) 
0.13 
ECMO (in ECMO centers only) 
24 (51.1%) 
16 (26.2%) 
0.007 
Inhaled nitric oxide 
45 (56.3%) 
39 (42.9%) 
0.045 
Sildenafil 
25 (31.3%) 
11 (12.1%) 
0.004 
Inotropics 
73 (91.3%) 
73 (80.2%) 
0.08 
Duration inotropics (days)  
(in survivors only) 
8 (4.25- 19) 
6 (3.25- 11.75) 
0.02 
Presence of pulmonary hypertension 
57 (71.3%) 
59 (65%) 
0.16 
Severity of pulmonary hypertension 
None 
20 (25%) 
29 (31.9%) 
 
< 2/3 systemic 
9 (11.3%) 
10 (11%) 
 
2/3 systemic – systemic 
26 (32.5%) 
26 (28.6%) 
 
> systemic 
22 (27.5%) 
21 (23%) 
 
Missing 
3 
5 
 
Switch to CMV 
24 
 
 
Switch to HFV 
 
14 
 
Treatment failures (hypoxemia or 
hypercarbia or hypotension or OI>40 or 
increase in inspiratory pressure 
27 (33.3%) 
20 (22%) 
0.01 
 

 
13 
2.3.2. Etiology of Pulmonary Hypertension Associated with CDH  
 
The histological findings of CDH show pulmonary vascular remodeling superimposed on 
hypoplasia or pruning of the vascular bed associated with structural and functional changes in 
the heart, airways and lung parenchyma (Gien and Kinsella 2016). Pulmonary hypertension 
associated with CDH is often severe and resistant to treatment with conventional pulmonary 
vasodilators such as iNO (1997) (Gien and Kinsella 2016). Poor oxygenation response to iNO and 
other conventional vasodilators may be secondary to: 
 
Right ventricular dysfunction: Remodeled pulmonary vasculature in CDH results in severe 
PPHN and leads to RV dysfunction. Milrinone significantly improves RV diastolic function and 
marginally increases RV systolic velocity in CDH (Patel 2012) resulting in improved pulmonary 
blood flow and oxygenation.  A recent case series from Royal Children’s Hospital, Melbourne, 
Australia demonstrated that 
right ventricular diastolic 
dysfunction measured by 
tissue Doppler on day 1 and 
2 of life correlated with 
length of stay and duration 
of respiratory support 
(Moenkemeyer and Patel 
2013). 
 
Left ventricular dysfunction: 
Abnormalities of the left 
ventricle have been reported 
in infants with CDH (Siebert, 
Haas et al. 1984, Schwartz, 
Vermilion et al. 1994). When 
compared to neonates with 
other causes of PPHN, 
infants with left sided CDH 
had significantly lower left 
ventricular mass assessed by 
echocardiography. 
Moreover, infants with CDH 
who required ECMO had a 
lower left ventricular mass 

 
14 
either by echocardiogram or at post-mortem, than those patients who did not require ECMO 
(Schwartz, Vermilion et al. 1994),(Siebert, Haas et al. 1984). Reduced left ventricular output has 
been documented in left sided and right sided CDH (Byrne, Keller et al. 2015). It has been 
proposed that reduced left ventricular mass contributes to functional LV hypoplasia and results 
in increased left atrial pressure and pulmonary venous hypertension (Kinsella, Ivy et al. 2005). 
This helps to explain why iNO and other pulmonary arterial dilators are perhaps less effective in 
diaphragmatic hernia. These agents can often worsen oxygenation in the presence of 
pulmonary venous hypertension and/or cardiac dysfunction (figure 2) (Lakshminrusimha 2012) 
in both children (Baird, Havalad et al. 2012) and adults (Bocchi, Bacal et al. 1994). 
Administration of an inodilator (an agent with both cardiac inotropic function and vasodilator 
effect) such as milrinone may improve LV dysfunction (figure 1) (Gien and Kinsella 2016) and 
promote pulmonary vasodilation and oxygenation (Cai, Su et al. 2008, Cai, Su et al. 2008).   
Induction of cAMP / cGMP degrading PDE 
by hyperoxia and iNO: Cyclic GMP and cAMP 
are important second messengers that 
promote pulmonary arterial smooth muscle 
cell 
relaxation 
(Figure 
3). 
Their 
concentration is regulated by specific 
phosphodiesterases such as the cGMP 
specific PDE5 and cAMP-specific PDE3. 
Animal models of PPHN demonstrate 
increased PDE3 expression, which could 
promote vascular dysfunction (Murray, 
MacLean et al. 2002). Recent laboratory 
studies 
also 
indicate 
that 
hyperoxic 
ventilation with iNO dramatically increases 
PDE3 activity (Chen, Lakshminrusimha et al. 
2009), suggesting that these therapies may 
reduce cAMP and paradoxically contribute to vascular dysfunction (Thelitz, Oishi et al. 2004). 
Inhibiting PDE3 by milrinone enhances cAMP levels and promotes vasodilation of pulmonary 
arterial rings in animal models of PPHN (Lakshminrusimha, Porta et al. 2009) and following 
hyperoxic ventilation and/or iNO (Chen, Lakshminrusimha et al. 2009) similar to that 
encountered by many babies with CDH.  
2.3.3. Milrinone 
 
Milrinone is a phosphodiesterase 3 (PDE3) inhibitor with inotropic and lusitropic effects that 
was approved in the 1980s for intravenous use in decompensated congestive heart failure. 

 
15 
Vascular PDE3 breaks down cAMP in arterial smooth muscle cells and myocardium. By 
inhibiting PDE3, milrinone also functions as a vasodilator independent of β1-adrenergic 
receptor stimulation and has been called an “inodilator” because of these dual effects (figure 2 
and 3) (Opie 1986, Lakshminrusimha and Steinhorn 2009, Lakshminrusimha and Steinhorn 
2013). Milrinone increases cAMP levels in cardiac muscle and vascular cells, improving 
ventricular function both directly and by reducing afterload (Lakshminrusimha, Konduri et al. 
2016). Intravenous or enteral sildenafil (a PDE5 inhibitor) is another pulmonary vasodilator with 
potential for use in CDH and is currently being investigated for chronic use in severe 
diaphragmatic hernia (NCT00133679). (Abman, Kinsella et al.) 
Animal models of PPHN: In an ovine model of PPHN induced by antenatal ductal ligation, 
milrinone relaxed pulmonary arterial rings in a dose dependent manner (Lakshminrusimha, Porta 
et al. 2009). This model of PPHN is associated with significant remodeling of the pulmonary artery 
with smooth muscle hypertrophy and muscularization of small, distal pulmonary arteries (Wild, 
Nickerson et al. 1989) similar to that described in infants with PPHN and CDH and was used in 
preclinical studies for iNO (Zayek, Cleveland et al. 1993). In the same model, an intravenous 
loading dose of 100µg/kg followed by 1µg/kg/min for an hour reduced pulmonary vascular 
resistance from 0.503 ± 0.06 mmHg/mL/kg/min to 0.383 ± 0.03 mmHg/mL/kg/min (p<0.05) and 
was not associated with a significant decrease in systemic mean blood pressure (54 ± 3 to 51 ± 
4mmHg) (Rashid, Morin et al. 2006). In lungs isolated from lambs with PPHN, protein levels of 
adenylate cyclase and PDE3A (the predominant PDE3 isoform in vascular tissue) were similar to 
control lambs without any change in PDE3A activity suggesting that the target enzymes for 
milrinone were unchanged by vascular remodeling in PPHN (Lakshminrusimha, Porta et al. 2009). 
Milrinone improves left ventricular output following cardiac surgery: The benefits of milrinone in 
children following surgery for congenital heart disease have been well established in several 
studies (including the randomized, double-blind PRIMACORP study, n=238)(Chang, Atz et al. 
1995, Bailey, Miller et al. 1999, Hoffman, Wernovsky et al. 2002, Hoffman, Wernovsky et al. 
2003). The PRIMACOR study was a double-masked, placebo-controlled trial conducted in 
neonates and young children following cardiac surgery (Hoffman, Wernovsky et al. 2003).  Three 
parallel groups (low dose, 25 µg/kg bolus over 60 minutes followed by a 0.25 µg/kg per min 
infusion for 35 hours; high dose, 75 µg/kg bolus followed by a 0.75 µg/kg per min infusion for 35 
hours; or placebo) were studied. The composite end point of death or the development of low 
cardiac output syndrome (LCOS) was evaluated at 36 hours and up to 30 days after 
randomization. Among 238 treated patients, 25.9%, 17.5%, and 11.7% in the placebo, low-dose 
milrinone, and high-dose milrinone groups, respectively, developed LCOS in the first 36 hours 
after surgery. High-dose milrinone significantly reduced the risk the development of LCOS 
compared with placebo, with a relative risk reduction of 55% (P = 0.023) in 238 treated patients 

 
16 
and 64% (P = 0.007) in 227 patients without major protocol violations. There were 2 deaths, both 
after infusion of study drug. The use of high-dose milrinone reduced the risk of the LCOS through 
the final visit by 48% (P = 0.049). This study established that the role of high-dose milrinone after 
pediatric congenital heart surgery to reduce the risk of LCOS. 
Case reports of milrinone use in PPHN not due to CDH: Anecdotal reports have shown that 
milrinone can be an effective therapeutic option in PPHN. (McNamara, Laique et al. 2006, Bassler, 
Kreutzer et al. 2010) These retrospective case reports from two different hospitals in Ontario, 
Canada looked at 24 critically ill late preterm/term infants (except one infant at 26 weeks 
postmenstrual age PMA) with HRF or PPHN unresponsive to iNO. Bassler et al reported 4 infants 
with PPHN. Some of the infants were “primed” with normal saline (15ml/kg) and administered a 
loading dose of 50 µg/kg over 30 min followed by 0.33 µg/kg/min. None of the infants developed 
systemic hypotension, and all of them showed consistent improvement in oxygenation. One of 
the infants was born at 26 weeks PMA and developed bilateral intraventricular hemorrhage (IVH) 
with moderate dilation of all ventricles. Another term infant developed an IVH. The third infant 
(39 weeks PMA) showed a small left subependymal hemorrhage. In a subsequent study, 
McNamara et al reported 9 term infants with PPHN with poor response to iNO who received IV 
milrinone. Because of the potential risk of systemic hypotension, a loading dose was avoided in 
these patients with PPHN. The infusion was started at 0.33 µg/kg/min and increased in 
increments of 0.33 according to clinical response to a maximum of 0.99 µg/kg/min. There was a 
significant improvement in oxygenation after commencement of milrinone, particularly in the 
first 24 h of infusion. Tachycardia improved and there was no hypotension. The same authors 
performed pharmacokinetic studies in 11 late preterm and term infants with PPHN resistant to 
iNO with a loading dose of 50 µg/kg over 60 min followed by an infusion of 0.33 to 0.99 µg/kg/min 
and demonstrated an improvement in oxygenation (figure 4) and RV / LV output and a reduction 
in pulmonary arterial pressure by echocardiography without any IVH (McNamara, Shivananda et 
al. 2012). 
Recently, James et al have described 17 term infants with PPHN resistant to iNO and treated 
with milrinone infusion (James, Corcoran et al. 2015). An echocardiogram was obtained one 
hour (median) prior to milrinone infusion. Milrinone infusion increased left ventricular output, 
right ventricular output, right ventricle strain and strain rate. These echocardiographic changes 
were associated with a reduction in iNO dose and oxygen requirement over the subsequent 72 
hours (James, Corcoran et al. 2015). There was a significant decrease in OI at 24 h post 
milrinone infusion and this effect persisted at 72 h [OI at baseline – 12 (6-21); 24 h – 5 (2-10) 
and 72 h – 3 (1-7)]. There was a reduction in systolic, diastolic and mean systemic blood 
pressures at 6 h after infusion with an increase in use of vasopressor medications. However, 
blood pressure began to increase after 12 h of milrinone administration with a peak at 72 h. 

 
17 
 
 Figure 4. Change in oxygenation index (OI) in patients with iNO resistant PPHN (does not 
include patients with CDH) treated with IV milrinone. * p < 0.05 compared to post iNO OI 
(McNamara, Shivananda et al. 2012). 
Pharmacokinetics of milrinone in late-preterm/term neonates: The half-life, total body 
clearance, volume of distribution and steady state concentration of milrinone in neonates with 
PPHN are shown in table 4. Similar values were obtained from 48 neonatal, post-op cardiac 
patients in the PRIMACORP study (table 4) which also showed that the clearance in neonates is 
only 25% of that in children (Bailey, Miller et al. 1999). With a constant-rate infusion, neonates 
take a much longer time to achieve steady-state concentration. Without a loading dose, 
neonates reached 50% of steady-state concentration by 2h (compared to 45min in older 
children). However, for the same infusion rate, the steady-state concentration will be higher in 
neonates than older patients. These findings underscore the necessity of a loading dose for 
rapid achievement of a therapeutic blood concentration in neonates, but lower infusion rate to 
avoid higher levels secondary to poor clearance (Bailey, Miller et al. 1999). Milrinone 
pharmacokinetics have also been evaluated in preterm infants (Paradisis, Jiang et al. 2007, 
Paradisis, Evans et al. 2009), infants following cardiac surgery (Lindsay, Barton et al. 1998, 
Hoffman, Wernovsky et al. 2003) and more recently in neonates with iNO resistant PPHN 
(McNamara, Shivananda et al. 2012) (table 4). It appears to be a safe and effective medication 
and has been used in 209 CDH patients without associated heart defects within the CDH 

 
18 
registry (Menon, Tani et al. 2012). Seventeen percent of patients with CDH in the Neonatal 
Research Network (NRN) are treated with milrinone. 
Table 4. Pharmacokinetic data on milrinone in adults, children, term and preterm neonates 
Study 
Adult (Young 
and Ward 
1988) 
Child 
(Bailey, 
Hoffman et 
al. 2004) 
Neonate (post-
op CHD) (Bailey, 
Miller et al. 
1999) 
Neonate 
(PPHN) 
(McNamara, 
Shivananda 
et al. 2012) 
Preterm 
neonate 
(Paradisis, Jiang 
et al. 2007) 
Gestational 
age/age 
Healthy adult 
volunteers 
Pediatric 
patients 
Neonates 
39.2 ± 1.3 
weeks 
14h (10-30h) 
26 weeks (23-
28) 
 
Weight (kg) 
 
5.9 ± 4*  
 
3.481 ± 0.603 0.85 (0.52-1.26) 
Half-life (h) 
0.8 ± 0.22 
3.7 
 
4.1 ± 1.1 
10.3 
Total body 
clearance 
(mL/kg/min) 
6.1 ± 1.3  
2.5 to 10.6 
(increases 
with age) 
1.64 ± 0.37  
1.83 ± 0.17 
0.64 
Volume of 
distribution 
(L/kg) 
0.32 ± 0.08 
0.7 – 0.9 
0.523 ± 0.028 
0.56 ± 0.19 
0.576 
Steady-state 
concentration 
(ng/mL) 
 
 
 
290.9 ± 77.7 
195 (78-257) at 
21h after 
infusion 
Dose regimen 12.5 to 75 
µg/kg load 
followed by 
0.5 
µg/kg/min 
25 to 75 µg 
/kg load 
followed 
by 0.25 to 
0.75 µg 
/kg/min 
infusion 
25 µg /kg over 
60 min followed 
by a 0.25 µg/kg/ 
min (low dose) 
or 75 mcg/kg 
load and 0.75 
µg/kg/min (high 
dose) 
50 mcg/kg 
load over 1h 
followed by 
0.33 (to 0.99) 
µg /kg/min 
0.75 
mcg/kg/min for 
3h followed by 
0.2 µg /kg/min 
* This weight is an approximate value - based on high dose arm in PRIMACORP study 
Milrinone in CDH: Patel recently reported improved right ventricular diastolic function and 
oxygenation in 6 neonates with CDH following milrinone infusion (table 5) (Patel 2012). All of 
them were treated with iNO or IV sildenafil or both. Four of these patients had undergone 
surgery prior to initiation of milrinone. Oxygenation index decreased from 10.6 ± 5.6 to 7.9 ± 
6.2 by 12-24h and to 5.1 ± 2.6 by 48-72h after commencement of milrinone infusion. The 
editorial accompanying this case report urged the need for randomized controlled trials of 
milrinone in CDH (Giaccone and Kirpalani 2012). Milrinone is commonly used during the 

 
19 
management of CDH without any randomized trials conducted to show benefit. Thirty percent 
of infants with CDH in the Children’s Hospital Neonatal Database (CHND) (Grover, Murthy et al. 
2015) and 22% of late-preterm and term infants with CDH in the Pediatrix database (Malowitz, 
Hornik et al. 2015) received milrinone. 
Table 5. Change in oxygenation index (OI) before and 12-24h and 48-72h after initiation of milrinone in CDH 
Patient # 
PRE-Milrinone 
12-24 h 
48-72h 
1 
18.9 
16.5 
9.1 
2 
13.1 
11.9 
5.3 
3* 
4 
8 
6.4 
3.3 
5 
4.25 
1.5 
2.5 
6 
8.9 
3.4 
5.2 
mean 
10.6 
7.95 
5.1 
SD 
5.6 
6.2 
2.6 
* Missing mean airway pressure values prevented accurate calculation of OI (Data courtesy Neil Patel MD, FRACP) 
Oxygenation index (OI) on the first blood gas after admission in CDH: Preliminary data obtained 
from the Medical College of Wisconsin, Milwaukee* (Khmour, Konduri et al. 2014),  University of 
Iowa† (Mann, Morriss et al. 2012) and Women and Children’s Hospital of Buffalo¶ on the OI 
obtained from the first gas after admission is shown below. Data at 6 h after admission are shown 
in table 6 below.  
Table 6.  Comparison between CDH patients who survived without ECMO and patients that 
needed ECMO and/or died prior to NICU discharge. Data shown are mean ± SD. The number 
in parenthesis is the number of patients in that category. 
 
Characteristic 
Survived without ECMO 
ECMO and/or death 
Death 
OI at admission 
(n=225) 
12 ± 10 (n=123) 
33 ± 16 (n=102) 
33 ± 18 (n=73) 
OI at 6 h after 
admission (n=127) 
9 ± 8 (n=81) 
29 ± 20 (n=46) 
26 ± 23 (n=27) 
Patients with OI ≥ 
10, 6 h after 
admission (n=57) 
20 ± 8 (n=21) 
 
 
35 ± 19 (n=36) 
35 ± 22 (n=18) 
* Data courtesy Dr. Mir Basir, MD – Medical College of Wisconsin; † data courtesy Dr. Jonathan Klein, MD – University of Iowa 
and ¶Ms. Ashley Williams, University at Buffalo. Please note that the number of patients with arterial blood gas data available 
at each time point is variable as this table does not represent a single cohort. 

 
20 
Based on table 6, among patients with an OI ≥ 10 at 6 hours after admission, the need for 
ECMO and/or risk of death before discharge is 36/57 = 63% and represents moderate to severe 
PPHN.  
Use of (PaO2 / FiO2) – PaCO2 index for stratifying severity of PPHN and lung hypoplasia in 
patients with CDH: The two main determinants of outcome in CDH are lung hypoplasia and 
PPHN. Arterial CO2 is an important predictor of outcome in infants with pulmonary hypoplasia 
due to CDH (Salas, Bhat et al. 2014). Oxygenation index is also a good predictor of PPHN 
(Ruttenstock, Wright et al. 2015) but does not take PaCO2 levels into account. An index that 
includes both oxygenation and ventilation parameters (such as (PaO2 / FiO2) – PaCO2 index) 
may be a better indicator of severity of PPHN and lung hypoplasia. A cut-off value of zero for 
this index distributes patients into moderate and high risk of ECMO/death (table 7). 
 
Table 7. Preliminary data: Outcomes – survival without ECMO, ECMO/death among infants 
with CDH with an OI of ≥ 10   6 hours after admission and stratified into severe and moderate 
hypoxemic respiratory failure (HRF) based on the (P/F ratio – PaCO2) index 
 
Index @ 6h after admission & OI ≥ 
10 
Survived without 
ECMO (n=21) 
ECMO and/or 
Died (n=37) 
 
Died 
(n=18) 
Severe HRF 
(P/F ratio – PaCO2) index ≤ 0 (n=21) 
3 (14%) 
18 (86%) 
8 (38%) 
Moderate HRF 
(P/F ratio – PaCO2) index > 0 (n=37) 
18 (49%) 
19 (51%) 
10 (27%) 
 
Milrinone lactate injection is currently indicated for the short-term (~48h) intravenous use in 
adults with decompensated cardiac failure. Being an “inodilator” and lusitrope, milrinone is 
likely to improve cardiac function and promote pulmonary vasodilation and be effective in 
managing PPHN associated with CDH. 
 
This investigation is not intended to support a new indication for use or any significant change 
in labeling for milrinone. This study does not involve change in route of administration. Only 
FDA approved milrinone products will be used in this study. FDA has exempted this study from 
requiring an IND. 
 
 

 
21 
2.4. 
JUSTIFICATION FOR THE STUDY 
 
Significance:  
Approximately 1600 newborn infants with CDH are born in the US every year 
(http://www.cherubs-cdh.org/) and CDH is an orphan disease that is excluded from many trials 
involving PPHN. The overall survival based on the CDH registry is 71% (75% for isolated CDH) 
(http://utsurg.uth.tmc.edu/pedisurgery/cdhsg/CDHSG.pdf) and has not significantly improved 
in the last 10-15 years. The main causes of mortality are pulmonary hypoplasia and therapy-
resistant pulmonary hypertension (figure 5). Survivors with CDH have long-term problems 
including 
pulmonary 
hypertension 
and chronic 
lung disease. 
In spite of 
high 
mortality, to 
date, only 
one 
randomized 
controlled 
study has 
been 
published 
evaluating 
the postnatal 
management 
of CDH. This 
study 
involving iNO 
was conducted through the Neonatal Research Network and the Canadian Institute of Health 
Research over 15 years ago. In the past decade, significant changes in mechanical ventilation, 
‘gentle’ approach to ventilation of newborn infants, since the NINOS-CDH study was completed, 
recognition of oxygen toxicity, tolerance to lower SpO2 and higher PaCO2 (permissive 
hypercapnia) and delayed surgical repair have changed the management of CDH.  
 
Seventeen percent of patients with CDH in the NRN currently receive milrinone (same as 
sildenafil) (table 9, page 33). Based on case reports, compelling low-level evidence exists that 

 
22 
milrinone may be beneficial in PPHN and possibly CDH. There is a potential for confounding and 
co-intervention bias secondary to the lack of a control group in these case series (Giaccone and 
Kirpalani 2012). Even in a small pilot study, randomization can strengthen results and make 
them more interpretable (Giaccone and Kirpalani 2012). 
 
Investigators: Congenital diaphragmatic hernia is a relatively rare condition and most patients 
are often referred to tertiary care centers. Approximately 10% of all cases in the US are cared 
for within the NRN. Many NRN investigators have experience in conducting trials on postnatal 
management of CDH (1997). The NRN is the ideal venue for conducting this pilot trial in the US. 
A successful pilot within the NRN may provide data for a multicenter definitive trial. With the 
change in the composition of NRN in 2016, the number of CDH patients has increased to 
approximately 227 / year. 
 
Innovation: We speculate that poor response to conventional therapy in CDH is related to left 
ventricular dysfunction in the immediate postnatal period followed by ventilation induced 
oxygen toxicity and volutrauma (figure 5). (Gien and Kinsella 2016, Snoek, Reiss et al. 2016)  
Improving cardiac dysfunction with milrinone in combination with “gentle” ventilation may 
potentially improve oxygenation and reduce the risk of chronic lung disease and the need for 
ECMO. To our knowledge, this is the first randomized trial using an inodilator in CDH. 
 
Approach: A prenatal consult by maternal-fetal medicine, surgery and/or neonatology is a 
common practice in many centers for mothers diagnosed with fetal CDH. Explaining the study 
to the parents and consenting during the antenatal period will allow us to enroll adequate 
number of patients. The intervention proposed in this protocol is intravenous infusion of 
milrinone, a medication that is commonly used in many NICUs. Based on the survey of NRN 
centers, 17% of babies with CDH already receive this medication (table 9).  It is not clear if this 
medication is used early in the course of the disease or after documenting a poor response to 
iNO or secondary to the presence of ventricular dysfunction.  
 
A potential problem with this protocol is slow recruitment. Based on the number of patients 
with CDH in the NRN, we anticipate that enrollment will be completed over a period of 24 to 36 
months. However, if enrollment is slow over the first 6 months, it will be crucial to increase 
consenting during the antenatal period and to enhance involvement of pediatric surgeons at 
these centers. 
 
Infants from all races and ethnicities and both genders will be included in this study. A Spanish 
consent form will be required by all sites with > 5% of subjects speaking Spanish only. 
  

 
23 
Environment: The Neonatal Research Network is ideally suited to conduct this pilot trial for the 
following reasons: 
(i) Vast experience with neonatal clinical trials 
(ii) Availability of an adequate number of patients to conduct this pilot trial 
(iii) Recent experience and training and lessons learnt from trials involving management of 
PPHN 
(iv) Many investigators in the NRN have experience in one of the two postnatal randomized 
controlled trials published in CDH population (NINOS 1997). 
(v) Excellent collaboration between neonatologists and pediatric surgeons in previous and 
ongoing trials (e.g., NEST – Laparotomy vs. drainage in necrotizing enterocolitis 
NCT01029353). 
 
 
 

 
24 
SECTION 3. 
STUDY DESIGN 
3.1. 
PRIMARY OUTCOME 
 
The primary outcome is the oxygenation response, as determined by change in OI (or OSI if no 
arterial blood gas is available) at 24h after initiation of study drug. In patients that require 
ECMO or die prior to completion of 24h from the initiation of the study drug, the last OI (or OSI, 
if no arterial blood gas is available) prior to initiation of ECMO or death will be used for analysis. 
A difference in OI of 4 points in mean change from baseline OI at 24 h between experimental 
and control groups will be considered  significant (OI increased by 4 ± 14.8 in the control group 
and decreased by 2.7 ± 23.4 following iNO in the CDH NINOS study (1997). In the Patel study, 
following milrinone infusion, OI decreased by 2.7 ± 1.7 from baseline by 12-24 h and 5.5 ± 3.2 
by 48-72 h; the mean change in OI of both these time points is a decrease by 4.1 ± 1.5 (Patel 
2012)). This outcome will be used for sample size calculation. Although a decrease in OI by 4 
points may not be clinically significant, this number is based on the only published case series 
showing the use of milrinone in CDH. In patients without an arterial line (or if the line is lost), 
oxygen saturation index (OSI) will be calculated using a preductal oximeter. (Rawat, 
Chandrasekharan et al. 2015) 
 
Oxygenation index (OI) = Mean airway pressure (cm H2O) x FIO2 x 100 ÷ PaO2 (mm Hg) 
Oxygen saturation index (OSI) = Mean airway pressure (cm H2O) x FIO2 x 100 ÷ SpO2 (%) 
 
3.2. 
SECONDARY OUTCOMES 
 
(i) Oxygenation response at 24 h after initiation of study drug assigning a minimum OI of 40 
or OSI of 20 (if no arterial blood gas is available) for subjects that need ECMO or die 
after initiation of study drug infusion but prior to 24h of study-drug infusion. In this 
analysis if the patient’s OI is 30 (or OSI of 15) and is cannulated for ECMO due to 
hemodynamic instability, he/she will be assigned an OI of 40 (or OSI of 20). However, if 
the OI prior to ECMO is 47 (i.e., > 40), the higher number (47) will be used for analysis of 
this secondary outcome. 
(ii) Oxygenation index at 48 and 72 h after initiation of study drug (or OI/OSI at the time of 
initiation of ECMO or immediately prior to death, for infants placed on ECMO or died 
before these time points), 
(iii) Change in echocardiographic findings – velocity of tricuspid regurgitation, left 
ventricular ejection fraction, position of the interventricular septum and direction of 
shunt at the PDA and PFO level – prior to and 24-72h after starting the study 

 
25 
medication.  This outcome will be available only for those infants who have a pre-study 
drug echocardiogram and a second echocardiogram between 24-72 h after initiation of 
study drug. These data will be extracted from echocardiograms performed for clinical 
indications. 
(iv) Vasoactive Inotrope score and systemic blood pressure 
(v) Area under the curve for inspired oxygen after initiation of the study drug over the first 
72 hours of study-drug infusion (or prior to ECMO or death, whichever is earlier) (Note: 
inspired oxygen and ventilator data from 4 time points per day – every 6 hours will be 
recorded to calculate area under the curve),  
(vi) If subsequent to the study drug, any additional inotrope or pulmonary vasodilator is 
used (such as iNO), we will evaluate the oxygenation response to these agents. If 
inotropes or vasodilators were used prior to the initiation of study drug, similar values 
will be recorded. The OI (or OSI) and PaO2/ FiO2 ratio prior to and after initiation of the 
inotrope / vasodilator are recorded (these data are recorded at 6 hour intervals; the 
date and time of initiation of individual inotropes and vasodilators is recorded). The 
change in OI (or OSI) and PaO2/ FiO2 ratio in response to these agents is evaluated as a 
continuous variable and arbitrarily classified into responders, partial responders and 
non-responders similar to prior trials (1997, 1997). 
a.  complete response is defined as an increase in PaO2/ FiO2 ratio > 20 mmHg from 
baseline,  
b. partial response is an increase in PaO2/ FiO2 ratio of 10 to 20 mmHg from 
baseline, 
c. no response is defined as an increase of < 10 mmHg (or a decrease) in PaO2/ FiO2 
ratio from baseline,  
d. the site of sampling (preductal vs. postductal) is also recorded. (Gien and Kinsella 
2016); right radial and ulnar arterial lines/sticks will be considered preductal; Left 
radial and ulnar arterial samples are usually preductal but can occasionally be 
postductal; umbilical arterial lines and posterior tibial lines (both sides) are 
always postductal. 
e. in patients without arterial access, an OSI (oxygen saturation index) will be used 
(vii) 
Supplemental oxygen at 28 d, and 56 d (or discharge, whichever comes earlier) 
from the hospital – primary institution or secondary institution to which patient was 
transferred. The use of supplemental oxygen at 28 d will be used to calculate the 
incidence of chronic lung disease. Chronic lung disease severity will be classified similar 
to the BPD classification in preterm infants at > 32 week gestation (Jobe and Bancalari 
2001). Intermittent supplemental oxygen given only during feedings or for spells 
administered for < 60 minutes and if the infant is not receiving oxygen at any other time 
during the day will not be considered as “supplemental oxygen”. 

 
26 
a. Time point of assessment:  28 d, 56 d postnatal age or discharge to home 
whichever comes first.  
b. Mild CLD: treatment with oxygen > 21% oxygen for at least 28 days but breathing 
room air by 56 days’ postnatal age or discharge to home whichever comes first. 
c. Moderate CLD: need for > 21% but < 30% oxygen at 56 days postnatal age or 
discharge to home whichever comes first. 
d. Severe CLD: need for ≥ 30% oxygen and/or positive pressure (high-flow nasal 
cannula – defined for the purpose of this study as > 2 LPM, non-invasive 
ventilation or nasal intermittent positive pressure ventilation – NIV or NIPPV, 
CPAP, or positive pressure ventilation) at 56 days’ postnatal age or discharge 
whichever comes first. 
(viii) 
Survival to discharge (or day 120, whichever comes earlier) without ECMO and 
(ix) Clinical status – pulmonary (use of supplemental oxygen or respiratory medications – 
pulmonary vasodilators (sildenafil, bosentan etc.,), diuretics, methylxanthines, steroids, 
inhaled or nebulized steroids or bronchodilators) and nutritional (weight, length, head 
circumference, use of anti-reflux and prokinetic medications) at discharge from the 
hospital and at 12 months of age. In addition, a review of clinical status will also be 
performed at 4 and 8 months of postnatal age. 
(x) Feasibility to perform a definitive trial (primary outcome – improvement in survival 
without ECMO) and safety (incidence of systemic hypotension, intracranial bleeding and 
arrhythmias) 
 
3.3. 
STUDY INTERVENTION 
 
The study intervention is an intravenous infusion of milrinone (only FDA approved milrinone 
products will be used in this study) or placebo (D5W). 
 
3.4. 
BLINDING/MASKING 
 
The intervention will be blinded by the study pharmacist at each center. Infants, parents, care-
givers will not be aware of the treatment assignment. 
 
Accidental unmasking: if the identity of the study drug is accidentally revealed to the research 
or the clinical team, data collection and analysis will continue as previously planned and a 
protocol violation will be documented. 
 
Intentional unmasking: if the neonatal/surgical attending requests unmasking based on the 
presence of a serious adverse event, he/she will be informed that the study drug may be 

 
27 
immediately stopped. The request for unmasking will be forwarded to the site PI, study PI and 
discussed with the NICHD-NRN director. If approved, the study pharmacist will be directed to 
reveal the identity of the study drug to the attending physician only and not the research team. 
If the neonatal/surgical attending requests unmasking based on a positive effect of the study 
drug, he/she will be informed that after the completion of study drug therapy, the clinical team 
may initiate open-label milrinone. 
 
3.5. 
POTENTIAL RISKS AND BENEFITS TO SUBJECTS 
 
Infants with CDH represent a high-risk population with mortality ranging from 30 to 40%. 
Additional risks from the use of IV milrinone include systemic hypotension, intracranial 
hemorrhage (reported in critically ill neonates with PPHN) and arrhythmias (reported in adults). 
The anticipated benefit is improvement in oxygenation and reduced need for ECMO. 
 
Systemic hypotension is commonly seen in patients with CDH. In recent studies 80-90% of 
patients with CDH required treatment with vasoactive medications. (Snoek, Capolupo et al. 
2016) Patients will be closely monitored for systemic hypotension due to its association with 
increased right –to-left shunting and hypoxemia.  Study drug will be discontinued in the 
presence of ‘severe’ or ‘life-threatening’ systemic hypotension as outlined in the MOP that 
cannot be explained by other causes (such as sepsis or pneumothorax) and described below. 
a. Severe hypotension:   
• decrement in mean BP > 20 to 30 mmHg compared to the most recent 
value during the period prior to study drug or at baseline OR 
• receiving extensive volume therapy (40 to 80 ml/kg during a 24-hour 
period of the study monitoring period: onset of study drug to 24 hours 
after discontinuation of study drug) OR  
• escalation of vasoactive inotrope score by 20 to 30 compared to the 
score at baseline 
b. Life-threatening hypotension:  
• Decrease in mean BP > 30 mmHg compared to the most recent value 
during the period prior to study drug or at baseline OR 
• receiving volume therapy (> 80 ml/kg during a 24-hour period of the 
study monitoring period: onset of study drug to 24 hours after 
discontinuation of study drug) OR  
• escalation of vasoactive inotrope score by > 30 compared to the score at 
baseline) 
 

 
28 
(i) 
Vasoactive inotrope score calculation (vasoactive inotrope score = dopamine dose 
(µg/kg/min) + dobutamine dose (µg/kg/min) + epinephrine dose (µg/kg/min x 100) + 
norepinephrine dose (µg/kg/min x 100) + phenylephrine dose (µg/kg/min x 100) + 
vasopressin dose (U/kg/min x 10000) (Gaies, Gurney et al. 2010) 
 
Intracranial hemorrhage has been reported in 2 patients with milrinone use in one case series. 
Subjects in the study will be closely monitored for intracranial hemorrhage with a first head 
ultrasound and a repeat ultrasound after completion of the study drug infusion. Study drug is 
discontinued if a ‘severe’ or ‘life-threatening’ intracranial bleed/echodensity as defined in the 
MOP and as described below. 
 
a. Severe intracranial bleed: unilateral or bilateral blood/echodensity filling the 
ventricle(s) resulting in distension without parenchymal bleeding and without a 
midline shift. 
b. Life-threatening intracranial bleed: Parenchymal hemorrhage/echodensity 
(including cerebellar hemorrhage) and / or any bleed/ echodensity associated 
with a midline shift. 
Extracranial hemorrhage has not been reported in neonates with PPHN receiving milrinone. 
However, the study-drug should be discontinued in the presence of ‘severe’ or ‘life-threatening’ 
extracranial bleed (that cannot be attributed to other factors such as trauma, surgery etc,) as 
outlined in the MOP and described below: 
 
a. Severe category:  
• pulmonary or GI or other forms of extracranial bleed requiring >15-30 
ml/kg PRBC transfusion during the study monitoring period: (onset of 
study drug to 24 hours after discontinuation of study drug) OR  
• associated with a 5 to 10 mm Hg decrease in mean blood pressure from 
the time prior to the onset of bleeding  
b. Life-threatening category:  pulmonary or GI or other forms of extracranial 
bleed requiring PRBC transfusions (total volume of PRBC > 30 ml/kg 
during the study monitoring period: onset of study drug to 24 hours after 
discontinuation of study drug) OR associated with > 10 mm Hg decrease 
in mean blood pressure from the time prior to onset of bleeding. 
 
 
Milrinone does not directly induce renal dysfunction. However, renal dysfunction can prolong 
the half-life of milrinone. New-onset renal dysfunction of ‘severe’ or ‘life-threatening’ category 
as outlined in the MOP ) are indications for discontinuation of study-drug. 

 
29 
 
a. Severe renal dysfunction: Serum creatinine > 2 mg/dL but ≤ 3 mg/dL OR 
increase by 0.5 to 1 mg/dL from the most recent value during the period 
prior to study drug or at baseline   
b. Life-threatening renal dysfunction: Serum creatinine > 3 mg/dL OR 
increase by > 1 mg/dL compared to the most recent value during the 
period prior to study drug or at baseline  
 
Milrinone use has been associated with arrhythmias in adults. Arrhythmias have not been 
reported in the neonatal population in the absence of cardiac disease or surgery. However, if 
‘severe’ or ‘life-threatening’ arrhythmias (as described in the MOP) are noted after the use of 
milrinone and other causes (such as electrolyte disturbances or presence of a central line in the 
right atrium) are ruled out, the study drug should be discontinued. 
 
a. Severe arrhythmia:  
i. 
rhythm abnormality including bradycardia (heart rate ≤ 70/min) or 
tachycardia (heart rate ≥ 220 but ≤ 300/min) OR  
ii. 
arrhythmia associated with a 5 to 10 mm Hg decrease in mean blood pressure 
from the time prior to the onset of arrhythmia OR 
iii. 
therapy with anti-arrhythmic medications,  AND 
iv. 
No use of pacing, cardioversion or defibrillation. 
b. Life-threatening arrythmia:  
i. 
rhythm abnormality – tachyarrhythmia with heart rate > 300/min OR 
ii. 
treated with pacing, cardioversion or defibrillation OR  
iii. 
arrhythmia associated with a > 10 mm Hg decrease in mean blood pressure 
from the time prior to the onset of arrhythmia  
 
Note: Respiratory deterioration (as reported on the toxicity table in the MOP) is common in the 
natural history of CDH and should not be a reason for discontinuing the study drug. 
 

 
30 
SECTION 4. 
METHODS 
4.1. 
STUDY POPULATION 
 
Infants with an antenatal or postnatal diagnosis of CDH will constitute the study population. 
Infants of all ethnicities and both sexes will be included. Stratification based on the severity of 
respiratory failure (PaO2/FiO2 – PaCO2) will be performed. If the (PaO2/FiO2 – PaCO2) is ≥ 0, 
subjects are stratified as moderate hypoxemic respiratory failure (HRF) and if < 0, as severe 
HRF.  If no arterial blood gas is available prior to randomization, an OSI of 5 to 10 is considered 
“moderate” HRF and > 10 is considered “severe” HRF. 
 
4.1.1. Inclusion Criteria 
 
Infants are eligible if they meet all of the following criteria: 
(i) ≥ 36 0/7 weeks PMA by best obstetric estimate AND birth weight of ≥ 2000g  
(ii) postnatal age ≤7 days (168 hours of age), including post-operative infants following CDH 
repair with HRF within this postnatal age, 
(iii) invasive mechanical ventilation (defined as ventilation with an endotracheal tube) and  
(iv) one arterial blood gas with an OI ≥ 10 (after tracheal tube obstruction, pneumothorax 
and other easily resolvable mechanical causes for increased OI are ruled out) on the 
most recent arterial blood gas within 12 hours prior to the time of randomization. 
(v)  if an arterial blood gas is not available at the time of randomization, a preductal OSI of ≥ 
5 can be used as an inclusion criterion instead of OI ≥ 10; (the OSI should be based on 
the most recent preductal pulse oximetry recording and must be within 12 hours of 
randomization) 
(vi) postnatal blood gas with PCO2 ≤ 80 mmHg (arterial, capillary or venous blood gas) on 
the most recent blood gas sample obtained within 12 hours prior to randomization 
Note: Criteria (iv) to (vi) must be met at the most recent analysis within 12 hours prior to 
randomization. 
 
4.1.2. Exclusion Criteria 
 
Infants are ineligible if they meet any of the following criteria: 
• known hypertrophic cardiomyopathy  
o Note 1: infants of diabetic mothers with asymmetric septal hypertrophy can be 
included as long as there is no evidence of obstruction to left ventricular outflow 
tract on echocardiogram, 

 
31 
o Note 2: infants with other acyanotic congenital heart disease (CHD) and CDH 
may be included in the study and will be a predetermined subgroup for analysis) 
• cyanotic CHD – transposition of great arteries (TGA), total anomalous pulmonary venous 
return (TAPVR), partial anomalous pulmonary venous return (PAPVR), truncus arteriosus 
(TA), tetralogy of Fallot (TOF), single ventricle physiology – hypoplastic left heart 
syndrome (HLHS), tricuspid atresia, critical pulmonic stenosis or atresia etc., 
• enrolled in conflicting clinical trials (such as a randomized controlled blinded trial of 
another pulmonary vasodilator therapy); Note: mothers enrolled in fetal tracheal 
occlusion studies such as FETO may be enrolled if permitted by investigators of the fetal 
tracheal occlusion study; More information about FETO can be found at 
http://www.chop.edu/centers-programs/center-fetal-diagnosis-and-
treatment/fetoscopic-endoluminal-tracheal-occlusion-feto or 
http://childrens.memorialhermann.org/FETO-trial/ [FETO refers to fetoscopic 
endoluminal tracheal occlusion and involves occlusion of fetal trachea with a balloon 
device at mid-gestation and subsequent removal in later gestation] 
• infants with bilateral CDH  
o Note 3: infants with anterior and central defects are included in the study 
• associated abnormalities of the trachea or esophagus (trachea-esophageal fistula, 
esophageal atresia, laryngeal web, tracheal agenesis) 
• renal dysfunction (with serum creatinine > 2 mg/dL not due to maternal factors) or 
oligohydramnios associated with renal dysfunction at randomization; renal dysfunction 
may be secondary to renal anomalies or medical conditions such as acute tubular 
necrosis 
• systemic hypotension (mean blood pressure < 35 mm Hg for at least 2 h with a 
vasoactive inotrope score of > 30) 
• decision is made to provide comfort/ palliative care and not full treatment 
• Known intracranial bleed (including the following descriptions on the cranial ultrasound) 
o Parenchymal hemorrhage – including blood in the cerebral parenchyma, 
cerebellar parenchyma or basal ganglia 
o Blood/echodensity in the ventricle with distension of the ventricle 
o Midline shift secondary to mass effect from an intracranial hemorrhage 
• thrombocytopenia (platelet count < 80,000/mm3) despite blood product administration 
on the most recent blood draw prior to randomization 
• coagulopathy (PT INR > 1.7) despite blood product administration on the most recent 
blood draw (if checked – there is no reason to check PT for the purpose of this study) 
• aneuploidy associated with short life span (such as trisomy 13 or 18) will not be included 
in the study (infants with trisomy 21 can be included in the study)   

Revised July 23, 2020; December 16, 2021 
32 
• use of milrinone infusion prior to randomization (the use of other inhaled pulmonary 
vasodilators such as iNO, inhaled epoprosternol, inhaled Treprostinil, inhaled PGE1 and 
oral such as endothelin receptor antagonists is permitted – Note: it is unlikely to be on 
oral pulmonary vasodilators early in the course of CDH) 
• ongoing therapy with parenteral (intravenous or subcutaneous) pulmonary vasodilators 
such as IV/SQ prostacyclin analogs (Epoprostenol – Flolan® or Treprostinil – 
Remodulin®) or IV phosphodiesterase 5 inhibitors (sildenafil – Revatio®) at the time of 
randomization.  Administration of IPGE1 is not an exclusion criteria.   In addition, 
initiation of therapy with these two classes of parenteral medications (except IPGE1) 
during the first 24 hours of study drug initiation is not permitted and will be considered 
a protocol deviation. The risk of systemic hypotension is high during the first 24 hours of 
study-drug (milrinone) infusion and hence parenteral administration of other pulmonary 
vasodilators is avoided to minimize risk of hypotension. 
• Subjects already on ECMO or patients who are being actively considered for ECMO by 
the neonatal or surgical team 
• Infants with hypoxic-ischemic encephalopathy (HIE) undergoing therapeutic 
hypothermia 
• attending (neonatal, critical care or surgical) refusal for participation in the trial 
(including concern about presence of hemodynamic instability) 
 
Note:  
1. A clotting profile evaluation is not required prior to enrollment. However, a cranial 
ultrasound (covered by the study budget) must be obtained either prior to initiation of 
study drug or within 4 hours of initiation of study drug. Not obtaining a cranial 
ultrasound within this time period will be considered a protocol deviation. 
2. One complete blood count (CBC) with a platelet count of > 80,000/ mm3 on the most 
recent evaluation prior to enrollment is required for randomization. This CBC may be 
drawn after one or multiple platelet transfusions.  
3. The use of therapies such as sedation, analgesia, paralysis, surfactant, high frequency 
ventilation, iNO, pressors, inhaled prostaglandins (including PGE1 and prostacyclin) and 
steroids are permitted at the discretion of the clinical team (and/or based on written 
center guidelines – a copy of each center’s guidelines, if available, will be collected prior 
to enrollment).  
4. Infants with CDH as part of a congenital syndrome that does not cause cardiopulmonary 
or renal compromise (e.g., rib cage anomalies, renal dysplasia) can be included in the 
study. Infants with trisomy 21 and CDH without cyanotic heart disease or kidney disease 
affecting renal function may be included in this trial.   

 
33 
5. A baseline echocardiogram (if ordered for clinical indications) prior to initiation of study 
drug or within 6 hours of initiation of study-drug is preferred as a baseline study. 
However, consenting, randomization and preparation of study drug by the pharmacy 
may proceed without an echocardiogram. It is not necessary to wait for the “official” 
results of the echocardiogram to commence study drug (unless there is a high suspicion 
for cyanotic congenital heart disease). 
 
4.2. 
DETAILED STUDY PROCEDURES 
 
For the purpose of the study, time period prior to study drug is defined as 12 hours prior to 
initiation to 30 minutes prior to initiation of study drug. Baseline is defined as the period 30 min 
prior to initiation of study drug. The monitoring period is defined as the period of study drug 
infusion and the first 24-hours following study drug cessation. 
 
4.2.1. Screening 
 
All mothers and infants with an antenatal or postnatal diagnosis of CDH will be included in 
screening.  
The screening log will include – confirmation of gestational age, birth weight and antenatal or 
postnatal diagnosis of CDH.  
 
4.2.2. Consent Procedures 
 
Mothers with an antenatal diagnosis of fetal CDH and infants admitted with a postnatal 
diagnosis of CDH will be screened and approached for consent. 
(i) In many institutions, mothers are referred by the Obstetrician and/or Maternal-Fetal 
Medicine (MFM) specialist for a consult with Pediatric Surgery and Neonatology. This 
would be an ideal time to obtain consent (brochures for distribution and consenting will 
be provided to all centers). 
(ii) Mothers admitted to labor and delivery with an antenatal diagnosis may be approached 
for consent (if not in active labor or on narcotic analgesia). 
(iii) Infants that are diagnosed postnatally, or born to mothers that could not be consented 
during the prenatal period or transferred from outside hospitals may be approached in 
the first 168 hours of life (7 days). 
(iv) Permission to access maternal records to record antenatal glucocorticoid therapy, 
ultrasound and MRI based assessment of severity of CDH will be requested at the time 
of consent (included in the consent form). 

 
34 
(v) Permission to access infant’s records from providers (subsequent hospitalizations, 
pediatric primary care providers and subspecialty consultants to obtain follow-up 
information until the baby’s first birthday will be requested at the time of consent 
(included in the consent form). 
 
4.2.3. Randomization Procedures 
 
The following information must be checked and/or confirmed prior to randomization. (a) chest 
X-ray to confirm the presence of unilateral CDH, (b) complete blood count – CBC to check 
platelet count and (c) a blood gas – arterial, venous or capillary to document a PCO2 ≤ 80 mm 
Hg.  These labs are routinely obtained to evaluate babies with suspected CDH in most 
institutions. Data from a baseline echocardiogram prior to initiation of study drug (if obtained 
for clinical purposes) is recorded but is not necessary for randomization (see 4.1.2 (5) above). 
 
(i) 
The diagnosis of CDH and the side of the defect must be confirmed with a chestX-
ray. 
(ii) 
Adequate platelet count (≥ 80,000/mm3) on the most recent CBC (after a platelet 
transfusion if necessary). 
(iii) 
Optional - An indwelling arterial line is placed (if not available oxygen saturation 
index or OSI is collected). 
(iv) 
Concurrent, ongoing therapy with a parenteral (IV/SQ) pulmonary vasodilator 
(milrinone, epoprostenol, treprostinil or sildenafil) is a contraindication to the study. 
(v) 
An arterial blood gas (preductal or postductal) with an oxygenation index of ≥ 10 (or 
OSI ≥5 in the absence of an arterial blood gas) and an arterial, venous or capillary 
blood gas with PCO2 ≤ 80 mmHg on the most recent blood gas (or pulse oximeter 
recording) should be recorded within 12 hours prior to randomization. An acute 
reversible mechanical factor such as endotracheal tube obstruction as a cause of 
elevated OI should be ruled out prior to randomization. If both preductal and 
postductal gases are available (this is rare), a preference is given to preductal – right 
radial or ulnar arterial draws, for calculation of OI. (Gien and Kinsella 2016) The 
same site (preductal or postductal) must be used at various time points for 
consistent comparison. 
(vi) 
Infants with CDH are eligible for enrollment if there are no exclusions and the most 
recent blood gas drawn within 12 hours prior to randomization has an OI ≥ 10. 
a. In patients without arterial access and/or an arterial blood gas, oxygen 
saturation index (OSI) can be calculated and if ≥ 5, randomization can be 
performed. 

 
35 
(vii) 
Once the infant meets these eligibility criteria and is randomized, the study drug 
infusion should start within 5 hours of randomization (if not, a protocol deviation 
form should be filled out). Once the infant is randomized, study drug is initiated 
even if a subsequent blood gas obtained for clinical purposes has an OI < 10 (or OSI 
is < 5 if there is no arterial blood gas). 
 
Eligible infants will be randomized to either milrinone arm or placebo arm using a phone or web 
system in a 1:1 ratio. 
 
4.2.4. Stratification:  
 
Patients will be stratified based on the severity of HRF using the prediction formula (PaO2/FiO2 
ratio – PaCO2 value) at the time of randomization. Patients with prediction value ≥ 0 will be 
considered as “moderate” and infants with a value of < 0 as “severe” HRF. If arterial line is not 
present prior to randomization, preductal OSI value of 5 to 10 (moderate) and > 10 (severe) will 
be used to determine severity of respiratory failure. 
 
In addition, side of the defect, center, prenatal (observed to expected lung to head ratio – LHR, 
position of the liver, lung volume assessment by MRI) (Ruano, Lazar et al. 2014), postnatal (OI 
(Ruttenstock, Wright et al. 2015), oxygen saturation index = mean airway pressure x FiO2 x 100 
÷ preductal SpO2) (Rawat, Chandrasekharan et al. 2015) (Park, Lee et al. 2013), evidence of 
pulmonary hypertension (velocity of the tricuspid regurgitation jet – if present, the position of 
the inter-ventricular septum and direction of shunt at the patent foramen ovale – PFO and 
patent ductus arteriosus – PDA level) and intraoperative (defect size) (Congenital 
Diaphragmatic Hernia Study, Lally et al. 2007) markers of disease severity will be recorded (but 
not used for stratification).  
 
4.2.5 In-hospital Procedures 
 
Pharmacy: Once the randomization code is received, the study pharmacist at the center will 
prepare an infusion of milrinone (pre-mixed bags contain 200 µg/mL of milrinone are preferred 
and do not need any further reconstitution in the pharmacy; Milrinone is also available in 1 
mg/mL solution for injection as 10-, 20-, and 50-mL single dose vials). Only FDA approved 
milrinone products will be used in this study.  Infusion is initiated at 0.33 µg/kg/min (20 
µg/kg/h; about 0.1 ml/kg/h) after priming the infusion circuit. An equivalent volume of 5% 
dextrose (D5W) will be used for infants randomized to the placebo arm. The premix solution in 
D5W has a pH of 3.2 to 4.0. Milrinone solution prepared from a single-dose vial is stable for 24 

 
36 
hours. The ready-to-use 200 µg/ml pre-mix solution is stable for a longer period of time if no 
further dilution/alterations are done. 
 
Although 0.9% saline, 0.45% saline and dextrose 5% can be used as diluents, only dilution with 
dextrose 5% solution is permitted. This is necessary to maintain similarity to premix bags and 
placebo (also dextrose 5% solution). 
 
Approximate time for compounding at the pharmacy using premixed solution on weekdays 
during daytime is approximately 30 min and during weekends and nights is 60-75 min based on 
staffing (data from Women and Children’s Hospital of Buffalo). A maximum duration of 5 hours 
is permitted between randomization and initiation of study drug. Failure to initiate study drug 
within this time frame is a protocol deviation. 
 
Dose: Milrinone/placebo will be initiated an infusion of 0.33 µg/kg/min (or 20 µg/kg/h or 0.1 
ml/kg/h of pre-mixed 200 µg/ml solution).  It is recommended that infants receive a fluid bolus 
(Lactated Ringers solution - preferred or 0.9% normal saline 10 mL/kg) before initiating study 
drug to avoid systemic hypotension, unless there is a contraindication.  If after 120 min of 
infusion of this dose of study drug (and within 240 min of study drug initiation), no evidence of 
hypotension (defined as mean blood pressure < 35 mmHg for at least 30 minutes) and a 
vasoactive inotrope score ≤ 30 (see below for calculation of vasoactive inotrope score) , the 
rate of the study drug infusion is increased to 0.66 µg/kg/min (40 µg/kg/h or 0.2 ml/kg/h of pre-
mixed solution). 
 
Compatibility: Milrinone is compatible with D5W, normal saline and Lactated Ringers solution. 
Milrinone is incompatible with furosemide, imipenem/cilastatin and procainamide.  
 
Vasoactive Inotrope score:  
 
A vasoactive inotrope score is a quantitative assessment of the degree of therapeutic support 
required by the patient to maintain adequate perfusion and/or blood pressure. It is calculated 
by the following equation (Rosenzweig, Starc et al. 1999, Kumar, Sharma et al. 2014, Maeda, 
Toda et al. 2015) (Gaies, Gurney et al. 2010): 
 
Inotrope score = dose of dopamine in µg/kg/min + dose of dobutamine in µg/kg/min + 100 X 
epinephrine dose in µg/kg/min + 100 X norepinephrine dose in µg/kg/min + 100 X 
phenylephrine dose in µg/kg/min) + vasopressin dose (U/kg/min x 10000)  
Note – the original formula includes 10 x milrinone dose (µg/kg/min). This has been excluded as 
patients will not be on open-label milrinone while on study drug infusion. 

 
37 
  
 
 
 
 
 
Figure 6. Initiation, maintenance and weaning of study drug (black line) in relation to oxygenation 
index (OI – orange shaded area). The study infusion is initiated at 0.33 µg/kg/min when OI ≥10. The 
dose is escalated to 0.66 µg/kg/min 2 to 4 h later if there are no adverse effects (mean BP < 35 mmHg 
and vasoactive inotrope score of > 30). The dose is maintained at 0.66 µg/kg/min for the duration of 
the study. The study drug is weaned to 0.33 µg/kg/min at 70h of infusion or if OI < 7 on two 
consecutive blood gases at least an hour apart (whichever time point is earlier). Two hours after the 
first wean, the study drug must be stopped.  Study drug is also stopped if there is a severe or life-
threatening adverse event (hypotension, hemorrhage, arrhythmia or renal dysfunction) 
 
Management of the patient: 
 
Management of the infant with CDH is completely based on center protocols or as per 
individual physician. The reference list includes publications on guidelines for CDH management 

 
38 
from the European consortium.(Reiss, Schaible et al. 2010) (Snoek, Capolupo et al. 2014, Snoek, 
Reiss et al. 2016) 
 
If the patient is found to have any of the following  criteria during the course of therapy, the 
study drug should be discontinued as described below.   
 
      (i)        Diagnosed with severe or life-threatening intracranial bleed/echodensity as defined in 
the MOP 
 
(ii) 
Diagnosed with severe or life-threatening renal dysfunction as defined in the MOP 
 
(iii) 
Diagnosed with severe or life-threatening arrhythmia as defined in the MOP not 
attributed to other causes such as electrolyte disturbances or a central line in the 
right atrium 
(iv) 
Diagnosed with severe or life-threatening intracranial bleed as defined in the MOP 
(v) 
Confirmed trisomy 13 or 18 by chromosomal analysis  
Note: Respiratory deterioration is common in the natural history of CDH and should not be a 
reason for discontinuing study drug. 
 
Duration of study intervention  
 
In the absence of complications: 
(i) 
Milrinone/placebo is continued until oxygenation improves and two OIs obtained at 
least one hour apart are less than 7 (OSI < 3.5, if no arterial blood gas is available), 
then weaned according to the protocol below, or 
(ii) 
Milrinone/placebo is weaned and discontinued after a maximum of 3 days of 
therapy (72 hours from the initiation).  
 
Surgery and ECMO: 
(i) 
Milrinone/placebo should preferably be continued if the patient requires ECMO 
irrespective of the mode of ECMO – VA vs. VV (Reason: although pharmacokinetics 
and volume of distribution are altered, milrinone may be beneficial with improved 
cardiac function especially during VV ECMO). (Note: ECMO use varies from center to 
center, but averages around 30%.  This will mean that a fair number of the high risk 
patients are excluded unless they are enrolled soon after birth) 
(ii) 
It is recommended that the study drug be continued through surgery. If the surgical 
team prefers to discontinue the study drug, this indication should be recorded and 
study drug weaned as per protocol. 

 
39 
(iii) 
Note: if the clinical team decides to wean the baby off the study drug prior to ECMO 
or surgery, these reasons are documented as indications for discontinuing the study 
drug. It is not considered a protocol deviation or violation to wean the medication 
prior to surgery or ECMO. If serious, potentially drug-related complications occur, 
drug should be discontinued immediately (without weaning). 
 
Study drug discontinuation criteria: 
 
Milrinone/placebo is discontinued (without weaning) if the patient develops ‘severe’ or 
‘life-threatening’ hypotension, intracranial or extracranial hemorrhage, renal 
dysfunction or arrhythmia that cannot be attributed to other causes. 
Note:  
 
The study drug can be discontinued (with or without weaning) by the clinical team at any time 
point if the team is concerned that the study drug poses a risk to the infant. An indication for 
discontinuation should be recorded.   The reason for discontinuation of study drug i.e., (a) due 
to completion of 72 h of infusion, (b) due to achievement of improved oxygenation (OI < 7 or 
OSI < 3.5, if no arterial blood gas is available), (c) secondary to occurrence of a side effect 
(intractable hypotension, intracranial hemorrhage, arrhythmia or renal dysfunction) or (d) due 
to a decision of the clinical team is recorded. 
 
Weaning of study drug (figure 6): 
 
(i) 
Once discontinuation criteria are reached, milrinone/placebo is weaned by 0.33 
µg/kg/min every two hours and discontinued (total duration of wean 2 h if the 
patient is on 0.66 µg/kg/min and abrupt cessation of the medication infusion if the 
patient is on 0.33 µg/kg/min). If the subject is on 0.66 µg/kg/min, weaning is 
initiated at 70 hours after initiation of study drug. If the subject is on 0.33 
µg/kg/min, no weaning is required and the study drug is stopped at 72 hours after 
initiation. NOTE: Once discontinuation criteria are reached and weaning is initiated, 
the study drug is discontinued after the wean. If the study drug is not weaned within 
4 hours of meeting discontinuation criteria, this is considered a protocol deviation. If 
the wean was initiated following two OI values of < 7 (or OSI of < 3.5) and 
oxygenation worsens after initiating the wean, the study drug should still be 
discontinued as the end-point was met. However, open-label milrinone can be 
started soon after discontinuation of the study drug. 

 
40 
(ii) 
If adverse events such as severe or life-threatening hypotension, intracranial or 
extracranial bleed,, arrhythmia or renal dysfunction are observed, study drug is 
abruptly stopped without gradual weaning. 
 
Open-label milrinone use: 
 
Immediately after completion of study intervention, open-label milrinone is permitted at the 
discretion of the clinical team. The study drug infusion will be 0.33 µg/kg/min at the time of 
cessation if gradual weaning protocol is adopted. It is recommended that the clinical team start 
open-label milrinone at this rate and adjust the dose based on clinical response. If the clinical 
team initiates open-label milrinone at 0.33 mcg/kg/min immediately after weaning the study 
drug, there is no discontinuity in therapy (for patients in the milrinone arm). 
 
Criteria for re-initiation of study drug: 
 
After the patient has met criteria for study drug discontinuation once (due to improvement in 
oxygenation and meeting OI criteria, or due to side effects such as severe hypotension, 
intracranial bleeding or renal dysfunction), study drug is discontinued and cannot be reinitiated 
even if the indication for initial discontinuation is resolved (for e.g., OI exceeds 10 after 
cessation of study drug or hypotension is resolved and blood pressure is normal etc.,). The 
clinical team may start open-label milrinone. 
 
During the post-study drug infusion period, data regarding open-label milrinone use, pressor 
use, and vasodilator use will be recorded for 24 hours after cessation of study-drug. 
 
Fluid intake: 
 
(i) 
As systemic hypotension and fluid bolus administration are common in 
patients with CDH and PPHN, it is important to record daily fluid intake. 
(ii) 
Total fluid intake (including maintenance fluids/TPN, flushes, medications, 
boluses and blood products) will be recorded for three 24-hour periods as 
entered in the nursing notes/EMR (please see MOP for details). 
 
Clinical criteria for ECMO: 
 
The decision to place an infant with CDH on ECMO is entirely up to the clinical team. Many 
centers prefer to use ECMO for preoperative stabilization. The following general guidelines are 
provided as criteria for ECMO (Reiss, Schaible et al. 2010) (Snoek, Reiss et al. 2016): 

 
41 
 
(i) 
Oxygenation index is consistently ≥ 40 for at least 3 h and/or 
(ii) 
Inability to maintain preductal saturations > 85% or postductal saturations > 70% and/or 
(iii) 
Increased PaCO2 and respiratory acidosis with pH < 7.15 despite optimization of 
ventilator management and/or 
(iv) 
PIP > 28 cm H2O or mean airway pressure > 17 cm H2O is required to achieve saturations 
> 85% and PaCO2 < 65 mmHg and/or 
(v) 
Inadequate oxygen delivery with metabolic acidosis as measured by elevated lactate ≥ 5 
mM/L and pH < 7.15 and/or 
(vi) 
Systemic hypotension (mean blood pressure < 30 mmHg), resistant to fluid and inotropic 
support, resulting in hypoperfusion and/or oliguria (urine output < 0.5 mL/kg/h) for at 
least 12-24h 
 
Subject specimens: Information about blood counts, imaging and blood gases will be obtained 
from blood draws conducted for the purpose of clinical care. No additional blood work will be 
performed for the purpose of research.  
 
Echocardiography: Data from a maximum of 4 clinical echocardiograms will be recorded. No 
additional echocardiograms will be performed for the purpose of this study. To estimate the 
secondary outcome of improvement in cardiac function and pulmonary hypertension, data 
from at least two echocardiograms will be obtained if available – the first echocardiogram 
preferably prior to initiation of the study drug. If echocardiogram is not performed prior to 
study drug initiation, study drug may be initiated.  
 
If clinical echocardiograms are obtained during the study drug infusion, data from the clinical 
echocardiogram closest to 24 hours after study drug infusion is used to calculate the secondary 
outcome of change in echocardiographic findings. If a third echocardiogram is obtained close to 
72 hours after initiation of study drug, data from this study will be recorded.  In addition, data 
from any other echocardiograms obtained for clinical purposes after completion of study drug 
will be recorded (maximum of 4 echocardiograms).  
 
Cranial ultrasound: As mentioned previously, an initial cranial ultrasound is obtained prior to 
initiation of study drug or within 4 hours of commencement of the study drug. A second cranial 
ultrasound is obtained preferably within 24 hours (maximum within 96 hours) of completion of 
the study drug. Both these cranial ultrasounds are covered by the study budget. Additional 
head imaging may be performed based on clinical indications but are not covered by the study 
budget. If the patient has a screening ultrasound that demonstrates intracranial hemorrhage 

 
42 
(as outlined in the exclusion criteria) prior to starting the study-drug, the patient is not 
randomized. In this case, only one screening cranial ultrasound is covered by the study budget. 
 
4.2.6 Post-hospital Procedures 
 
No procedures are required after discharge from the hospital (except for a telephonic 
questionnaire conducted at 4, 8, and 12 months of age – see 4.2.7 below). 
 
4.2.7 Additional Follow-up Examinations and/or Questionnaires 
 
The subject’s pulmonary and nutritional status will be initially recorded at discharge. 
Subsequently, a study questionnaire evaluating breathing outcomes and nutritional status will 
be administered at 4, 8, and 12 months of age by a telephonic interview. This questionnaire is a 
modification of the questionnaire used for the SUPPORT trial. (Stevens, Finer et al. 2014) 
 
 

 
43 
SECTION 5. 
ANALYTICAL PLAN 
5.1 SAMPLE SIZE AND POWER ESTIMATES 
 
Sample Size: In the case series describing the effect of milrinone among neonates with CDH, 
baseline OI (mean ± SD) was 10.6 ± 5.6, and improved to 7.9 ± 6.2 and 5.1 ± 2.6 at 12-24 h and 
at 48-72 h, respectively (Patel 2012).  Assuming that children receiving placebo will have no 
additional change in OI (mean change in OI = 0 at 24 hours), that children receiving milrinone 
will improve to a mean OI of 6.0 (a mean change in OI of 4.6) at 24 hours, and that the standard 
deviation of the change from baseline OI at 24 hours in each group is 6.2, 33 subjects in the 
control group and 33 subjects in the milrinone group would have 84% power to detect this 
difference with a two-sided alpha of 0.05 (note that 6.2 is a conservative standard deviation 
estimate, as data from the Patel et al study indicate that the standard deviation for change 
from baseline in OI at 24 hours may be as low as 1.5).  Phrased differently, if both the control 
and treatment OI’s were to change, for any given difference in OI, the sample size would be 
sufficient to detect an effect size of 0.7 with a power of 84%. The sample size will be sufficient 
to provide estimates of adverse event rates in the treatment group.  The following table 
provides the 95% confidence intervals for observed adverse event rates varying from 6% to 49% 
for a sample size of 33 subjects. 
 
Table 8. Confidence Intervals for Observed adverse event rates. 
Point 
estimate 
0.06 
0.09 
0.21 
0.30 
0.39 
0.49 
95% CI 
(0.007, 0.2) 
(0.02, 
0.24) 
(0.09, 
0.39) 
(0.16, 
0.49) 
(0.23, 
0.59) 
(0.31, 
0.66) 
 
Within the NRN centers, approximately 36% of neonates with CDH who are ≥ 36 weeks PMA 
require ECMO. In a selective population (isolated CDH with OI ≥ 10), we estimate that the risk of 
ECMO or death prior to discharge (or by day 120) will be approximately 40%. A sample size of 
33 in the placebo arm would provide a 95% confidence interval for this estimate of (26%, 58%).  
The precision of estimates for outcome rates in the treatment group can be seen in table 8. 
Limitations:  
(a) This study is not powered to compare rates of the outcome of death or ECMO between groups.  
To detect a reduction of 10% (from 40% incidence of death/ECMO in control arm to 30% 
incidence in the milrinone arm), with a 1:1 ratio of treatment and control subjects, a power of 
0.8 and an alpha value of 0.05, we would require 376 subjects in each arm.  

 
44 
(b) The study is also not powered to compare a sicker cohort of CDH patients similar to that 
evaluated in the CDH NINOs study (1997). The patients in CDH NINOs study had an OI of 
approximately 45 with standard deviations of 16.3 and 14.5 in control and treatment groups 
respectively. Such a cohort will require a sample size of 207 patients in each arm to achieve the 
primary outcome outlines in the current protocol. We intend to enroll patients early at a lower 
OI (or OSI). 
 
5.2 AVAILABLE POPULATION 
Available population/duration of the study: There are currently no protocols involving 
term/late preterm infants with CDH in the NRN (except the observational study for early-onset 
sepsis which does not interfere with this protocol). The International CDH study group (not 
associated with NRN) comprises of approximately 75 centers. These centers enrolled 300 
babies into the registry in 2009. The number of babies with CDH within the NRN per year was 
approximately 170/ year from 2011 to 2012. More recent data obtained from the NRN grant 
applications shows a higher number (approximately 227/ year). Information about the number 
of patients available within the NRN during 2011 and 2012 is given in table 9.  
 
Table 9. Infants with congenital diaphragmatic hernia in the Neonatal Research Network 
 
2011 2012 
Average 
Total CDH admissions 
175 
162 
169 
CDH ≥ 36 0/7 week PMA 
142 
133 
138 (82%) 
Inhaled NO in the preoperative period among CDH ≥ 36 0/7 
weeks PMA 
71 
72 
72 (43%) 
Other medications used in the preoperative period among CDH 
≥ 36 0/7 weeks PMA 
Milrinone 
Sildenafil  
Flolan ® (inhaled epoprostenol)  
Flolan ® (intravenous epoprostenol)  
Alprostadil (intravenous PGE1) 
Epinephrine  
 
 
17 
29 
8 
6 
6 
2 
 
 
29 
25 
9 
3 
5 
1 
 
 
23 (17%) 
27 (20%) 
9 (6%) 
5 (3%)  
6 (4%)  
2 (1%)  
ECMO among all CDH 
59 
56 
58 (34%) 
ECMO among CDH ≥ 36 0/7 weeks PMA 
51 
48 
50 (36%) 
Survival to discharge  
- all CDH 
- CDH ≥ 36 0/7 weeks   PMA 
 
111 
94 
 
117 
101 
 
114 (68%) 
98 (71%) 
Concern regarding use of iNO in CDH 
Yes – 8; No – 11  
Primary physician managing pulmonary vasodilator therapy 
Surgeons – 4; Neonatologists – 10; Joint (surgeons + neonatologists – 3); PICU – 1 

 
45 
Duration of study (figure 7): 
 
(i) 
There are approximately 138 babies with CDH ≥ 36 weeks PMA per year within the 
NRN. 
(ii) 
Eighty percent of CDH patients have isolated CDH without other major anomalies 
(138 x 0.8 = 110 patients).  
(iii) 
Approximately 35% of these patients do not meet inclusion criteria (OI < 10 mild 
disease or severe disease and/or hemodynamic instability): 110 x 0.65 = 71 patients 
(based on preliminary calculations using 11 patients in Buffalo and 116 patients from 
Milwaukee). 
(iv) 
Refusal to participate in the study (parents and/ or physician not consenting to the 
study or are cared by another service that does not want participation in a trial) – 
50%: 71 X 0.5 = 35 patients per year or 66 patients in approximately 2 years (figure 
7).  
 
5.3 PROJECTED RECRUITMENT TIME 
 
We anticipate that it will take 24 to 36 months for enrollment and an additional year for 
administering the pulmonary/ nutritional status questionnaire. It will take approximately 48 
months for the completion of this pilot study. Infants with CDH are a special population with 
high morbidity and mortality. We anticipate that enrollment might be slower than expected. 
 
 
 
 
 
 
 

 
46 
 
Figure 7. 
Outline of the 
study  

 
47 
5.4 STATISTICAL ANALYSIS PLAN 
 
Baseline data will be collected prior to randomization including gestational age, side of the 
diaphragmatic hernia, birth weight, mode of delivery and arterial blood gas parameters 
(oxygenation index-OI) and/or pulse oximetry data (oxygen saturation index-OSI). Data from a 
baseline clinical echocardiogram is recorded (if performed prior to study drug initiation or 
within 2h of initiation of study drug). During the infusion of study drug, arterial blood gas 
parameters and hemodynamic data (blood pressure, heart rate and echocardiography results) 
will be recorded. After completing the study infusion, surgical details, and mortality information 
will be collected. Among survivors, respiratory and nutritional status at discharge and at 4, 8 
and 12 months of age will be collected. 
 
Data will be presented as mean ± SD for normally distributed variables and as median and 
ranges (with percentiles) for non-normally distributed data. All analysis will be by intention-to-
treat. Baseline characteristics will be compared between treatment groups using chi-square and 
Fisher’s exact test for discrete variables and t-test and ANOVA for continuous variables. The 
primary outcome, difference from baseline OI at 24 h, will be compared between treatment 
groups using a general linear model adjusted for the stratification factor of HRF severity. Other 
continuous outcomes will be analyzed similarly. Models for longitudinal outcomes such as 
oxygenation and vasoactive inotrope scores (short-term) and nutritional and pulmonary 
outcomes at 12 months (long-term) will include the effect of time, the interaction between 
time and treatment, and random effects to account for the correlation between measures 
taken on the same individual over time. Categorical outcomes will be analyzed using analogous 
generalized linear models. Cox regression models (with adjustment for HRF severity) will be 
used to plot proportion of responders who survive without ECMO against survival time in 
hours. Analyses may adjust for clinical site if treatment assignments are severely imbalanced for 
some sites provided that it is computationally feasible to do so. The potential influence of 
baseline measures such as time of diagnosis – antenatal vs. postnatal, side of the defect, and 
gender on pulmonary and nutritional outcome will be explored through the use of additional 
models similar to those described above. 
 
5.5 DATA MONITORING PLAN 
 
The DSMC will monitor the progress of the trial on a routine basis for monitoring enrollment 
progress and reviewing the accruing safety data. The DSMC will meet to look over the 
preliminary data after enrolling the first 10 subjects.  Interim reviews are scheduled via e-mail 
or teleconference if DSMC identifies any emerging safety issues. A suggested schedule for 
further meetings based on subject enrollment is as follows: 

Revised December 16, 2021 
48 
 
25% enrollment (~ 17 subjects),  
50% enrollment (33 subjects) 
75% enrollment (~ 50 subjects) 
Completion of enrollment (~ 66 subjects) 
 
5.5.1 Reporting Adverse Events 
 
There is high morbidity and mortality associated with the natural course of CDH. The following 
measures will be used to monitor safety of the trial based on a review of adverse events. 
Adverse event reporting will be handled as follows:  
(i) 
Potential Adverse Events (as defined below) will be reported on the Adverse 
Events form.  
(ii) 
Because of the nature of the study population, mild events will not be 
recorded as adverse events unless they are also unexpected. 
(iii) 
Potential adverse events listed below that are severe, life-threatening or 
result in death (as per the MOP toxicity table) will be entered in the 
electronic data capture system (EDC) within 24 hours of discovery. 
(iv) 
Serious Adverse Events will be reported on the Adverse Events form, 
entered in the electronic data capture system (EDC) and reported to NICHD 
and the NRN data center within 24 hours of discovery (via SAE Narrative) 
when: 
a) 
 they result in death or  
b)  they are possibly, probably or definitely related to the intervention or 
c) 
 they are unexpected.  An unexpected event is defined as an adverse 
event not known to be associated with the natural course of CDH or a 
specified side-effect of interventions in the management of CDH. 
(v) 
All serious adverse events that meet one of the above criteria will be 
reviewed by the NICHD NRN Program Scientist (as medical monitor). 
(vi) 
All serious events that are marked as at least possibly related to the 
intervention will be forwarded to the Chair of the independent NRN DSMC 
for any further action.  
 
  
The duration of reporting adverse events would include the period of administration of the 
study drug and 24 hours’ post-infusion. This period will cover approximately 6 half-lives of 
milrinone and plasma levels are expected to be undetectable by 24 hours after completion of 
study-drug infusion. 
 

 
49 
5.5.2 Potential Adverse Events 
 
The potential adverse events include: 
 
1. Systemic hypotension 
2. Abnormal cranial imaging consistent with intracranial bleed 
3. Arrhythmias 
4. Extracranial bleeding (especially pulmonary and gastrointestinal hemorrhage) 
5. Renal dysfunction 
6. Respiratory deterioration 
7. Other events that are deemed severe (or worse in intensity), and either unexpected or 
at least possibly related to study or results in death 
 
The data regarding serious adverse events will be reviewed after recruitment of the first 10 
subjects. Subsequently, data regarding adverse events will be reviewed every 17 subjects (25% 
of the sample size). If DSMC is concerned about adverse events, the subjects can be unmasked 
for the DSMC to assess whether the event rates appear to differ between treatment arms. 
Should there be excess serious adverse events in one group, the committee may recommend 
breaking of the blinding and discontinuation of enrollment.  
 
5.5.3 Interim Monitoring Plan and Stopping Rules 
 
As mentioned previously, the DSMC will meet as per the following plan. A suggested schedule 
may include meeting after the first 10 subjects are enrolled and at 25% (~ 17 subjects), 50% (33 
subjects), 75% (~ 50 subjects) of target sample size and after completion of enrollment. 
 
In addition to monitoring trial progress, the DSMC will also review accumulating safety data for 
the trial. All safety data presented to the DSMC will be blinded to treatment group, though the 
report may be unmasked at the DSMC’s request. 
 
The three main adverse events that require close monitoring include severe hypotension , 
hemorrhage (intracranial and extracranial) and arrhythmia or death due to severe hypotension 
or intracranial hemorrhage or arrhythmia while on study drug infusion or 24 hours after 
cessation of study drug infusion.  
 
The presence of the following adverse events possibly, probably or definitely due to the study 
drug in > 20% of subjects after enrollment of 33 patients with a statistically significant 
difference between the treatment arm and the placebo arm can lead to a discussion at DSMC 
regarding cessation of the trial. 

 
50 
(a) Severe hypotension is defined by a decrease in mean blood pressure > 20 to 30 mmHg 
compared to baseline OR receiving extensive volume therapy (>40 to 80 ml/kg during a 
24 hour period of the study monitoring period OR escalation of vasoactive inotropic 
score by >20 to 30 compared to baseline) The study monitoring period is the time on 
study drug therapy and within 24 hours of completion of study drug therapy.  
(b) Life-threatening hypotension - receiving volume therapy > 80 ml/kg during a 24 hour 
period of the study monitoring period OR escalation of vasoactive inotropic score by > 
30 compared to baseline 
(c) Severe intracranial hemorrhage (unilateral or bilateral blood/ echodensity filling the 
ventricle(s) resulting in distension without parenchymal bleeding and without a midline 
shift) while on study drug therapy and within 24 hours of completion of study drug 
therapy. 
(d) Life-threatening intracranial hemorrhage - Parenchymal hemorrhage/ echodensity 
(including cerebellar hemorrhage) and / or any bleed/ echodensity associated with a 
midline shift. 
(e) Severe arrhythmia – heart rate rhythm abnormality including bradycardia (heart rate ≤ 
70/min) or tachycardia (heart rate 220 to 300/min) OR treated with anti-arrhythmic 
medications and no use of pacing, cardioversion or defibrillation OR associated with a 5 
to 10 mm Hg decrease in MBP from the time prior to the onset of arrhythmia 
(f) Life-threatening arrhythmia - tachyarrhythmia with heart rate > 300/min OR treated 
with pacing, cardioversion or defibrillation OR associated with a > 10 mm Hg decrease in 
MBP from the time prior to the onset of arrhythmia 
(g) Death – resulting from severe hypotension, hemorrhage or arrhythmia. 
 
5.5.3.1 Monitoring Enrollment 
 
Because the focus of the study is to evaluate changes in oxygenation and determine the 
feasibility of conducting a larger randomized trial, the DSMC will routinely review enrollment 
rates on this study to assess whether the enrollment rates are likely to be insufficient to 
support a full randomized trial to determine the impact of milrinone on survival without ECMO.  
For the current pilot trial, we anticipate 3 patients to be enrolled per month. Given this accrual 
target, it is anticipated that at least 12 patients will be enrolled in the 6-month period after at 
least 75% of sites have begun randomization and enrollment. 
 
This study will provide valuable data about CDH patients, response to various pulmonary 
vasodilators and pulmonary / nutritional outcomes at 12 months of age. Since this is a pilot trial 
to determine feasibility of a larger trial examining survival without ECMO as the primary 

 
51 
outcome, the interim efficacy of the Milrinone with respect to oxygenation will not be used as a 
criterion for stopping the study. 
 
5.5.3.2 Future Plans: 
 
Information obtained from this trial will be used for designing a definitive trial with a primary 
outcome of survival to discharge (or day 120, whichever is earlier) without ECMO. Preliminary 
sample size for the definitive trial is 752 (376 patients in each arm) and will require 
international collaboration (16 patients enrolled per month to complete the trial in 4 years).

 
52 
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