Effect of DHA on Proinflammatory Cytokines Including Platelets Activating Factor (PAF) in Preterm Neonates
Condition: Neonatal Disease
MeSH terms: Infant, Newborn, Diseases
Study type: Interventional

Summary: 
      The purpose of this study is to determine whether docosahexaenoic acid is effective in the
      prevention or reducing severity of necrotizing enterocolitis in preterm/low birth weight
      neonates.Necrotizing enterocolitis (NEC) is the most devastating gastrointestinal disease in
      neonates. The pathogenesis of NEC is not well defined but evidence strongly suggests that it
      is multifactorial . prematurity and enteral feeding are major risk factors for NEC. An
      excessive inflammatory response by the immature intestine to external stimuli, impaired
      intestinal barrier integrity and / or abnormal bacterial colonization are key factors
      implicated in pathophysiology of NEC.
    

Detailed description: 
      Inclusion criteria:

      Patients are eligible for inclusion if they meet the following criteria:

      Preterm neonates having a gestational age equal or less than 32 weeks at birth, admitted in
      Ain Shams University NICU'S.

      Weight (less than or equal 1.500 KG) Clinically stable to begin enteral feeding All Genders
      (Male, Female) Written informed consent by parents Sepsis will not be considered as exclusion
      criteria (according to SNAP 11; this score considers six physiologic variables such as blood
      pressure, temperature, the Po2/Fio2 ratio, serum PH, seizures and urine output, Töllner score
      (table 3) and Rodwell score (table 4)).

      Exclusion criteria:

      Persistent bleeding at any level. Receiving medication to avoid coagulation. Persistent
      vomiting. Gastrointestinal malformations. Mother taking Omega-3 supplements and planning to
      breastfed. The enrolled patients will be subdivided into two groups; group A are infants
      receiving DHA, group B are infants receiving placebo (physically matched solution).

      Our patient will be classified into two groups:

      Group A (interventional group/ DHA):

      A minimum of 40 preterm infants will be included to receive 100mg DHA daily administered by
      enteral route for 30 days. This group will be subdivided into breast fed / artificially fed
      infants.

      Group B (control group / Placebo):

      40 of preterm infant controls will be included to receive placebo (physically matched
      solution). This group will be subdivided into breast fed / artificially fed infants.

      Sample size:

      The sample size is calculated for the two groups receiving DHA versus Placebo. The sample
      size is calculated using the incidence densities of NEC reported in the literature of
      4.4/1000 and 17.3/1000 baby day. At least 20 babies should be included in each arm to reach
      an effect size of 0.8 with alpha error = 0.05 and power 0.80 (G*Power 3.1.7, Franz Faul,
      Universität Kiel, Germany, 2013).

      Randomization and blinding:

      Group A and B assigned according to a predetermined schedule generated from random numbers
      based on a computer-generated randomization sequence into either DHA or Placebo.

      Methods All infants will receive the standard neonatal care and will undergo follow-up from
      birth until reach 37 weeks corrected gestational age, discharge or death whichever comes
      first.

      Feeding protocol: (Ellard and Anderson, 2012):

      Begin as early as the neonate can tolerate.(when hemodynamically stable.) Start with low
      volume 0.5 to 1 ml/6 hours, increasing gradually according to the tolerance (trophic feeding
      10-20 ml/kg) start deduction of feds from total fluid intake thereafter Gut priming is not
      used in patients with severe hemodynamic instability, suspected or confirmed NEC Increment
      from 10 to 20 ml/kg/day.

      DHA supplementation:

      Group (A): 100 mg DHA will be given to all neonates in group A as soon as possible with the
      enteral feeding for 30 days (subtracted from the total volume of the feed).

      Group (B): will predominantly receive placebo (physically matched solution) together with
      their regular feeding.

      All patients and controls subjected to:

      Data Collection: Careful history taking Antenatal history including: rupture of membrane,
      Chorioamnionitis, history of urinary tract infection.

      Natal history including: mode of delivery, place of delivery, the need for resuscitation,
      recorded Apgar score at 1minute and 5 minutes.

      Postnatal history including: age of admission in neonatal intensive care unit, symptoms
      suggest infection.

      Thorough clinical assessment:

      Weight, length and OFC (twice weekly). Complete examination including cardiovascular,
      respiratory, and neurological examination.

      Abdominal examination will done focusing on: signs of feeding intolerance including:

      Measurement of abdominal girth Intestinal sounds Passage of stool Prescence of gastric
      residual Abdominal tenderness and rigidity NEC BELL'S criteria; as an objective tool for
      diagnosis and staging of NEC.

      Laboratory investigations:

      Complete blood picture, C-reactive protein, bleeding profile. Blood culture and sensitivity.
      Quantitative ELISA technique for PAF done for both cases and controls done twice. beseline
      sample will be withdrawn once NEC is suspected and the other one will be withdrawn 10 days
      from the first sample.( to assess the decrease in PAF levels).

      BLOOD SAMPLES:

      10ml of venous blood were withdrawn from each subject .they were divided into: 2ml collected
      on EDTA tube for CBC 1.8ml collected on sodium citrate for PT, PC and INR. The remaining part
      was collected in aplain tube, left to clot for 10-20 min at room temperature before
      centrifugation for 10 mins at the spend of 2000-3000 r.p.m., then serum was separated and
      divided into 2 aliquots, one for the blood chemistry which was assayed on the same day of
      sample collection, the second sample was stored at -20 C till the time of assay.

      Radiological investigations:

      Abdominal X-ray Erect & Supine (when necrotizing enterocolitis is suspected). Abdominal
      ultrasound (when necrotizing enterocolitis is suspected). MRI brain as an assessment tool for
      cerebral white matter abnormalities (White matter abnormalities scoring system).

      Follow-up and end-point of the study:

        1. Primary outcome:

           All infants will undergo follow-up from birth until reach 37 week corrected gestational
           age, discharge or death whichever comes first. The following primary outcome data will
           be recorded:

           Clinical examination and radiological investigations when clinically indicated for
           evidence of NEC.

        2. A secondary outcome measure :

           Arthropemetric measures as weight increment per kg per week, length, OFC, duration of
           hospitalization, mortality if any, monitoring adverse effects of treatment (if any);
           such as emesis, increased gastric residuals, increased abdominal girth, diarrhea, skin
           rash. Long term outcome includes necrotizing enterocolitis, bronchopulmonary dysplasia
           and intracranial hemorrhage.

           At term equivalent, all preterm infants underwent a structural MRI scan that was
           analysed qualitatively for the prescence and severity of cerebral white matter
           abnormalities, including cysts, signal abnormalities, loss of white matter volume,
           ventriculomegally, and corpus callosal thinning/myelination. (Each infant's scan was
           then graded using a qualitative scoring system consisting of five 3-point scales
           assessing the presence and severity of periventricular white matter volume loss, white
           matter signal abnormality, the presence of cystic abnormalities, ventricular dilation,
           and thinning of the corpus callosum and reduced myelination . children were classified
           as follows: 1) no abnormalities (score of 5 to 6) ; 2) mild abnormalities (score of 7 to
           9) ; 3) moderate abnormalities (score of 10 to12) ; or 4) severe abnormalities (score
           >12).

        3. Tertiary outcome:

      After discharge, all children underwent a comprehensive neurodevelopmental assessment using
      Bayley scale of infant and Toddler Development -111 (Bayley-111)
    

Intervention name(s): DHA
Intervention type(s): Dietary Supplement
Intervention description(s): Oral supplement
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Care Provider)
Primary purpose: Diagnostic