Clinical trial NCT03913221
Conditions: Hypoxic-Ischemic Encephalopathy
Sponsor: University of North Carolina, Chapel Hill
Start date: 2019-08-14; Completion date: 2024-12-31
Enrollment: 17 participants; Allocation: NON_RANDOMIZED; Intervention model: SEQUENTIAL

Brief summary:
Hypoxic-ischemic encephalopathy (HIE) due to perinatal asphyxia is common and often fatal. Therapeutic hypothermia reduces mortality and morbidity in infants with HIE. Even with the widespread use of therapeutic hypothermia, \~60% of infants with HIE die or have neurodevelopmental impairment. As a result, there is an urgent, unmet public health need to develop adjuvant therapies to improve survival and neurodevelopmental outcomes in this population.

Caffeine may offer neuroprotection for infants with HIE by blocking adenosine receptors in the brain and reducing neuronal cell death. In animal models of HIE, caffeine reduces white matter brain injury. Drugs in the same class as caffeine (i.e., methylxanthines) have been shown to be protective against acute kidney injury in the setting of HIE. However, their safety and efficacy have not been studied in the setting of therapeutic hypothermia and their effect on neurological outcomes is not known. Since these drugs reduce injury to the kidney in infants with HIE, they may also reduce injury to the brain.

This phase I study will evaluate the pharmacokinetics, safety, and preliminary effectiveness of caffeine as an adjuvant therapy to improve neurodevelopmental outcomes in infants with HIE.

Detailed description:

Arms: arm 1: Within 24 hours of delivery, participants will receive low dose administration of Caffeine citrate. arm 2: Within 24 hours of delivery, participants will receive high dose administration of Caffeine citrate.
Interventions: intervention 1: Caffeine Citrate 5 mg/kg intervention 2: Caffeine Citrate 10 mg/kg
Intervention descriptions: intervention 1: Loading dose of caffeine 20 mg/kg IV followed by two daily doses of 5 mg/kg IV. intervention 2: Loading dose of caffeine 20 mg/kg IV followed by two daily doses of 10 mg/kg IV.

Protocol documents:
Prot_SAP_000.pdf: 
 
 
Pharmacokinetics and Safety of Caffeine in Neonates with Hypoxic-
Ischemic Encephalopathy 
 
 
NCT number NCT03913221 
Document Date 06/26/2019 
 


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Pharmacokinetics and Safety of Caffeine in Neonates with Hypoxic-
Ischemic Encephalopathy  
 
Phase I Trial 
IND 143335 
National Clinical Trial (NCT) Identified Number: pending 
Principal Investigator: Wesley M. Jackson, MD, MPH 
Funded by: Thrasher Research Fund 
Version Number: v.1.2 
26 June 2019 
 
 
 
 


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Table of Contents 
 
 
page 
Statement of Compliance .............................................................................................................. 1 
1 
Protocol Summary ................................................................................................................ 2 
1.1 
Synopsis ................................................................................................................... 2 
1.2 
Schema .................................................................................................................... 3 
1.3 
Schedule of Activities (SoA) ..................................................................................... 4 
2 
Introduction .......................................................................................................................... 5 
2.1 
Study Rationale ........................................................................................................ 5 
2.2 
Background .............................................................................................................. 5 
2.3 
Risk/Benefit Assessment .......................................................................................... 7 
2.3.1 
Known Potential Risks .............................................................................................. 7 
2.3.2 
Known Potential Benefits ......................................................................................... 7 
2.3.3 
Assessment of Potential Risks and Benefits ............................................................ 8 
3 
Objectives and Endpoints .................................................................................................... 9 
4 
Study Design ...................................................................................................................... 11 
4.1 
Overall Design ........................................................................................................ 11 
4.2 
Scientific Rationale for Study Design ..................................................................... 11 
4.3 
Justification for Dose .............................................................................................. 11 
4.4 
End of Study Definition ........................................................................................... 11 
5 
Study population ................................................................................................................ 12 
5.1 
Inclusion Criteria ..................................................................................................... 12 
5.2 
Exclusion Criteria ................................................................................................... 12 
5.3 
Lifestyle Considerations ......................................................................................... 12 
5.4 
Screen Failures ...................................................................................................... 12 
5.5 
Strategies for Recruitment and Retention .............................................................. 12 
6 
Study Intervention .............................................................................................................. 13 
6.1 
Study Intervention(s) Administration ...................................................................... 13 
6.1.1 
Study Intervention Description ............................................................................... 13 
6.1.2 
Dosing and Administration ..................................................................................... 13 
6.2 
Preparation/Handling/Storage/Accountability ......................................................... 13 
6.2.1 
Acquisition and Accountability ................................................................................ 13 
6.2.2 
Formulation, Appearance, Packaging, and Labeling .............................................. 13 
6.2.3 
Product Storage and Stability ................................................................................. 13 
6.2.4 
Preparation ............................................................................................................. 13 
6.3 
Measures to Minimize Bias: Randomization and Blinding ...................................... 14 
6.4 
Study Intervention Compliance .............................................................................. 14 
6.5 
Concomitant Therapy ............................................................................................. 14 
6.5.1 
Rescue Medicine .................................................................................................... 14 
7 
Study Intervention Discontinuation and Participant Discontinuation/Withdrawal ............... 15 
7.1 
Discontinuation of Study Intervention ..................................................................... 15 
7.2 
Participant Discontinuation/Withdrawal from the Study .......................................... 15 
7.3 
Lost to Follow-up .................................................................................................... 15 
8 
Study Assessments and Procedures ................................................................................. 17 
8.1 
Study Procedures ................................................................................................... 17 


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8.1.1 
Screening/Baseline ................................................................................................ 17 
8.1.2 
Treatment ............................................................................................................... 18 
8.1.3 
Follow-up Period .................................................................................................... 19 
8.1.4 
Discharge/Transfer/Death ...................................................................................... 19 
8.1.5 
Final Study Assessment ......................................................................................... 20 
8.1.6 
Efficacy Assessments (Preliminary) ....................................................................... 20 
8.2 
Safety and Other Assessments .............................................................................. 21 
8.2.1 
Laboratory Evaluations ........................................................................................... 21 
8.2.2 
Special Assays ....................................................................................................... 22 
8.3 
Adverse Events and Serious Adverse Events ........................................................ 23 
8.3.1 
Definition of Adverse Events (AE) .......................................................................... 23 
8.3.2 
Definition of Serious Adverse Events (SAE) .......................................................... 23 
8.3.3 
Classification of an Adverse Event ......................................................................... 23 
8.3.3.1 Severity of Event .................................................................................................... 23 
8.3.3.2 Relationship to Study Intervention .......................................................................... 23 
8.3.3.3 Expectedness ......................................................................................................... 24 
8.3.4 
Time Period and Frequency for Event Assessment and Follow-up........................ 24 
8.3.5 
Adverse Event Reporting ....................................................................................... 24 
8.3.6 
Serious Adverse Event Reporting .......................................................................... 25 
8.3.7 
Reporting Events to Participants ............................................................................ 25 
8.3.8 
Events of Special Interest ....................................................................................... 25 
8.3.9 
Reporting of Pregnancy .......................................................................................... 25 
8.4 
Unanticipated Problems ......................................................................................... 25 
8.4.1 
Definition of Unanticipated Problems (UP) ............................................................. 25 
8.4.2 
Unanticipated Problem Reporting .......................................................................... 26 
8.4.3 
Reporting Unanticipated Problems to Participants ................................................. 26 
9 
Statistical Considerations ................................................................................................... 27 
9.1 
Statistical Hypotheses ............................................................................................ 27 
9.2 
Sample Size Determination .................................................................................... 27 
9.3 
Populations for Analyses ........................................................................................ 27 
9.4 
Statistical Analyses ................................................................................................ 28 
9.4.1 
General Approach .................................................................................................. 28 
9.4.2 
Analysis of the Primary Endpoint(s) ....................................................................... 28 
9.4.3 
Analysis of the Secondary Endpoint(s) .................................................................. 28 
9.4.4 
Safety Analyses ...................................................................................................... 29 
9.4.4.1 Clinical Definitions .................................................................................................. 29 
9.4.5 
Baseline Descriptive Statistics ............................................................................... 30 
9.4.6 
Planned Interim Analyses ....................................................................................... 30 
9.4.7 
Sub-group Analyses ............................................................................................... 30 
9.4.8 
Tabulation of Individual Participant Data ................................................................ 30 
9.4.9 
Exploratory Analyses .............................................................................................. 30 
10 
Supporting Documentation and Operational Considerations ............................................. 31 
10.1 
Regulatory, Ethical, and Study Oversight Considerations ...................................... 31 


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10.1.1 Informed Consent Process ..................................................................................... 31 
10.1.1.1 
Consent/Assent and Other Informational Documents Provided to 
Participants ............................................................................................................. 31 
10.1.1.2 
Consent Procedures and Documentation ................................................... 31 
10.1.2 Study Discontinuation and Closure ........................................................................ 31 
10.1.3 Confidentiality and Privacy ..................................................................................... 32 
10.1.4 Future Use of Stored Specimens and Data ............................................................ 32 
10.1.5 Key Roles and Study Governance ......................................................................... 32 
10.1.6 Safety Oversight ..................................................................................................... 33 
10.1.7 Clinical Monitoring .................................................................................................. 33 
10.1.8 Quality Assurance and Quality Control .................................................................. 33 
10.1.9 Data Handling and Record Keeping ....................................................................... 33 
10.1.9.1 
Data Collection and Management Responsibilities .................................... 33 
10.1.9.2 
Study Records Retention ............................................................................ 34 
10.1.10 
Protocol Deviations ..................................................................................... 34 
10.1.11 
Publication and Data Sharing Policy .......................................................... 34 
10.1.12 
Conflict of Interest Policy ............................................................................ 35 
10.2 
Additional Considerations ....................................................................................... 35 
10.3 
Abbreviations .......................................................................................................... 35 
10.4 
Protocol Amendment History .................................................................................. 37 
11 
References ......................................................................................................................... 39 
 


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Statement of Compliance 
 
The trial will be carried out in accordance with International Conference on Harmonisation Good 
Clinical Practice (ICH GCP) and the following:  
 
• 
United States (US) Code of Federal Regulations (CFR) applicable to clinical studies (45 
CFR Part 46, 21 CFR Part 50, 21 CFR Part 56, 21 CFR Part 312, and/or 21 CFR Part 812)  
 
National Institutes of Health (NIH)-funded investigators and clinical trial site staff who are 
responsible for the conduct, management, or oversight of NIH-funded clinical trials have 
completed Human Subjects Protection and ICH GCP Training. 
 
The protocol, informed consent form(s), recruitment materials, and all participant materials will 
be submitted to the Institutional Review Board (IRB) for review and approval.  Approval of both 
the protocol and the consent form must be obtained before any participant is enrolled.  Any 
amendment to the protocol will require review and approval by the IRB before the changes are 
implemented to the study.  In addition, all changes to the consent form will be IRB-approved; a 
determination will be made regarding whether a new consent needs to be obtained from 
participants who provided consent, using a previously approved consent form. 
 
 


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PROTOCOL SUMMARY 
1.1 
Synopsis 
Title: 
Pharmacokinetics and Safety of Caffeine in Neonates with Hypoxic-
Ischemic Encephalopathy 
Study Description: 
This is a phase I, open-label, dose-escalating pharmacokinetics (PK) and 
safety study of caffeine in neonates with hypoxic-ischemic encephalopathy 
undergoing therapeutic hypothermia. We hypothesize that drug clearance will 
be ≥ 20% lower than expected for gestational age and birth weight and that 
the incidence of adverse events will be within 20% of published results of 
neonates treated with therapeutic hypothermia in the NICHD Total Body 
Hypothermia for Neonatal Encephalopathy trial.   
Objectives: 
Primary Objective: Characterize the PK of caffeine in neonates undergoing 
therapeutic hypothermia for hypoxic-ischemic encephalopathy (HIE). 
 
Secondary Objectives: Characterize the safety of caffeine in neonates 
undergoing therapeutic hypothermia for HIE. Evaluate the preliminary 
effectiveness of caffeine in reducing brain injury in neonates with HIE.  
Endpoints: 
Primary Endpoint: 
PK: Caffeine clearance 
 
Secondary Endpoints: 
Safety: Adverse events Note: Seizures and necrotizing enterocolitis will be 
AEs of special interest 
Preliminary effectiveness: Death, abnormal MRI findings, neurodevelopment 
at 18-24 months 
 
Study Population: 
Inclusion Criteria 
1. Documented informed consent from parent or guardian  
2. ≥ 36 weeks gestational age at birth 
3. Receiving therapeutic hypothermia for a diagnosis of HIE 
4. Intravenous (IV) access 
5. Postnatal age < 24 hours 
Exclusion Criteria 
1. Receiving > 1 anti-epileptic drug for seizures 
2. Sustained (>4 hours) heart rate > 180 beats per minute 
3. Known major congenital anomaly 
4. Any condition which would make the participant, in the opinion of the 
investigator, unsuitable for the study 
Phase: 
1 
Description of 
Sites/Facilities Enrolling 
Participants: 
Up to 3 US Neonatal Intensive Care Units, including The University of North 
Carolina at Chapel Hill Newborn Critical Care Center  
Description of Study 
Intervention: 
Cohort 1 (N = 9): Caffeine IV 20 mg/kg loading dose, followed by 5 mg/kg q 
24 hours x 2 doses. 
Cohort 2 (N = 9): Caffeine IV 20 mg/kg loading dose, followed by 10 mg/kg q 
24 hours x 2 doses. 
Note: An interim safety analysis will be conducted following the follow-up 
period in the final cohort 1 participant and prior to enrolling in cohort 2.  
Study Duration: 
24 months 
Participant Duration: 
24 months  


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1.2 
Schema 
 


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1.3 
Schedule of Activities (SoA) 
 
Screen/ Baseline 
Treatment 
Follow-up Period 
Discharge/Transfer 
/Death 
Final study 
assessment 
Time point 
< 24 hours postnatal 
age 
Study day 1-3 
7 days following last 
caffeine dose 
 
18-24 Months 
Informed consent 
X 
 
 
 
 
Demographics 
X 
 
 
 
 
Neurological Exam 
X 
 
 
X 
X 
Weight 
X 
X 
X 
X 
X 
Medical history 
X 
 
 
 
X1 
Respiratory Support 
X2 
X2 
X2 
X 
 
Laboratory 
evaluations3 
X 
X 
X 
 
 
Urine output 
X 
X 
X 
 
 
Caffeine 
administration4 
 
X 
 
 
 
Concomitant 
medications 
 
X 
X 
 
 
Adverse events5 
 
X 
X 
 
 
PK sampling6 
 
X 
X 
 
 
Epigenetic sampling7 
 
X 
X 
 
 
Clinical events of 
interest8 
 
X 
X 
 
 
Head imaging9 
 
X 
X 
X 
 
Hearing screen  
 
 
 
X 
 
Surgical procedures 
 
X 
X 
X 
 
Bayley-III composite 
scores and GMFCS 
 
 
 
 
X 
.  1 Follow-up visit will include information on  hearing impairment requiring hearing aids, blindness, and cerebral palsy diagnosis.  2 Highest respiratory 
support (room air, oxyhood, nasal cannula/CPAP, or mechanical ventilation) and maximum FIO2 exposure during each 24-hour period.  3 See Section 
8.2.1.  4 Includes exact start, stop, and flush times for all caffeine doses.  5 Seizures requiring > 1 anti-epileptic drug and necrotizing enterocolitis are 
adverse events of special interest.   6 Date and time for each sample.  7 Obtained from scavenged blood samples, if available.  8 Includes death, sepsis, 
disseminated intravascular coagulopathy, hypotension, hypertension, hepatic dysfunction, acute kidney injury, persistent pulmonary hypertension, and 
thrombocytopenia. 9 Includes cranial ultrasounds and head CT, if done per standard of care, and brain MRI.  
 
 


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2 
INTRODUCTION 
2.1 
Study Rationale 
Hypoxic-ischemic encephalopathy (HIE) due to perinatal asphyxia is a common and often 
fatal disease in neonates. HIE occurs in nearly 1% of live births.1 Neonates with HIE 
experience a temporary interruption in blood flow to the brain and body around the time of 
delivery. This results in tissue hypoxia with subsequent damage to the brain and other vital 
organs.2 Encephalopathy manifests as abnormalities in the neurological exam, which can 
include seizures and alterations in levels of consciousness, muscle tone, and breathing 
patterns. The severity of encephalopathy is categorized into three stages (mild, moderate, and 
severe) based on the Sarnat grading scale.3  
Therapeutic hypothermia reduces morbidity and mortality in neonates with HIE. 
Therapeutic hypothermia reduces the risk of death or neurodevelopmental impairment (NDI) at 
18-24 months in neonates with moderate to severe HIE (number needed to treat is 7).4-10 Even 
with therapeutic hypothermia, mortality or NDI remains ~60% in neonates with HIE.10 As a 
result, there is an urgent, unmet public health need to develop adjuvant therapies to improve 
neurodevelopmental outcomes in this population. 
Adjuvant therapies are being investigated to improve outcomes in neonates with HIE 
(Table 1). These agents primarily target the effects of reperfusion injury in the brain which 
occurs 6-48 hours following the initial insult as a result of inflammation, oxidative stress, and 
excitotoxicity leading to cell death.11 All studies, with the exception of erythropoietin and 
allopurinol, are early phase trials and none of these therapies are currently approved or have 
demonstrated definitive benefits for HIE. Caffeine has not yet been investigated for 
neuroprotection in neonates with HIE.   
Table 1. Adjuvant therapies under investigation for HIE 
Therapy 
Clinicaltrials.gov 
Erythropoetin12,13 
NCT01913340; NCT02811263* 
Darbepoetin alfa14,15 
NCT01471015 
Autologous cord blood stem cells16,17 
NCT02612155; NCT02434965 
Melatonin18 
NCT02621944 
Xenon19,20 
NCT00934700; NCT01545271 
Allopurinol21,22 
NCT03162653** 
Topiramate23 
NCT01241019; NCT01765218 
Clonidine 
NCT01862250 
Anticipated Phase III completion: *September 2022; **December 2020 
2.2 
Background 
Caffeine is an appealing therapeutic for neuroprotection in neonates with HIE. Caffeine 
given for apnea of prematurity reduces NDI at 18-21 months.24,25 In addition, methylxanthines 
(the same drug class as caffeine) also reduce the incidence of acute kidney injury in neonates 
with HIE.26-32 Caffeine competitively binds to and blocks the action of adenosine receptors in the 
brain. Mechanisms by which caffeine may offer neuroprotection are the reversal of hypoxia-
induced delayed maturation of oligodendrocytes, the cells which produce myelin in the central 
nervous system,33 and anti-inflammatory and anti-oxidative properties which protect against 
reperfusion injury.34-36 Methylxanthines reduce neuronal cell death in animal models of HIE.37-39 
Thus, caffeine may improve neurologic outcomes in neonates with HIE. 


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The pharmacokinetics (PK) and safety of caffeine in neonates with HIE is unknown.  
Caffeine PK and safety are well-described in neonates treated for apnea of prematurity.40-42 
However, ischemic injury and therapeutic hypothermia alter the PK of medications, including 
morphine and gentamicin.43,44 As caffeine is primarily metabolized by the hepatic cytochrome 
enzyme CYP1A2 and excreted in the urine, ischemic injury to the liver and kidneys may reduce 
its clearance. Additional areas of uncertainty regarding caffeine in the setting of HIE include 
optimal dosing and safety. There is evidence that caffeine at doses > 36 mg/kg may lower 
seizure threshold.45-47 Therefore, PK and safety data for caffeine in the setting of HIE and 
therapeutic hypothermia are needed.  
Brain injury on MRI is a reliable biomarker for neurodevelopmental outcome in neonates 
with HIE. The NICHD Neonatal Research Network validated an MRI scoring system that 
categorizes severity of brain injury in the therapeutic hypothermia trial.5 Abnormal MRI findings 
were lower in the treatment group compared to the control group (48% vs 65%) and the results 
were independently associated with NDI at 18-22 months48 and intelligence quotient at 6-7 
years of age.49  
 
In-hospital morbidities in a cohort of neonates receiving caffeine while undergoing 
therapeutic hypothermia for HIE are similar to those published in cooling trials. We 
reviewed data from the Pediatrix Medical Group, a national consortium of neonatal intensive 
care units (NICUs) with ~90,000 admissions per year.50 We examined all inborn neonates with 
HIE who received therapeutic hypothermia and methylxanthine therapy (caffeine or 
aminophylline) in the first three postnatal days between 2007-2016. We recorded frequencies of 
death, mechanical ventilation, acute kidney injury (AKI; defined as creatinine rise > 0.3 mg/dL in 
a 48-hour period), hepatic dysfunction, receipt of anticonvulsant medication (defined as 
phenobarbital, fosphenytoin, or levetiracetam), and duration of hospitalization. We compared 
these frequencies to the results from three trials of therapeutic hypothermia.4-6 There were 26 
neonates who received methylxanthines in the setting of therapeutic hypothermia – 17 received 
caffeine, 8 received aminophylline, and one neonate received both. The frequency of AKI in 
neonates receiving caffeine was 25% (3/12) (Table 2).  
 
Table 2. Mortality and morbidity in neonates with HIE who received methylxanthines and 
in treated (i.e., received therapeutic hypothermia) groups from therapeutic hypothermia 
trials.  
 
Caffeine group 
(n=18) 
Aminophylline group 
(n=9) 
Treated* Groups in 
Previous Trials 
(n=373) 
 
Death 
13 (2/16) 
0 (0/6) 
19-334-6  
Duration of hospitalization in days, median (IQR) 
19 (16-32) 
15 (9-16) 
205  
Renal  
  Creatinine rise > 0.3 mg/dL in 48 hour period 
  Creatinine > 1.0 mg/dL 
25 (3/12) 
38 (5/13) 
56 (5/9) 
89 (8/9) 
N/A 
654 
Hepatic 
  Prothrombin Time > 16 s 
  AST > 200 U/L or ALT >100 U/L 
100 (7/7) 
56 (5/9) 
86 (6/7) 
38 (3/8) 
416 
20-384,5 
Neurologic 
 
 
 
  Receiving anticonvulsant in first postnatal week 
 
44 (8/18) 
 
44 (4/9) 
 
385 
 
*Treated indicates infants enrolled in the trials who received therapeutic hypothermia. Column percentages unless 
otherwise noted. IQR: Interquartile Range; AST: Aspartate Aminotransferase; ALT: Alanine Aminotransferase.  
 


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Determining the PK and safety of caffeine in neonates undergoing therapeutic 
hypothermia for HIE is an urgent, unmet public health need. Investigating caffeine as an 
adjuvant therapy for therapeutic hypothermia represents an ideal opportunity to approach the 
problem of the research gap of drugs in neonates with HIE because: 1) HIE is a relatively 
common diagnosis in the perinatal period; 2) Neonates with HIE are at increased risk of death 
or neurodevelopmental impairment; and 3) Preventing mortality and morbidities associated with 
HIE has life-long benefits. This study will provide the necessary first step to design next phase 
trial to evaluate the preliminary effectiveness of caffeine in reducing brain injury in neonates with 
HIE. If successful, caffeine will offer providers a cost-effective and safe treatment for 
neuroprotection in neonates with HIE.  
 
2.3 
Risk/Benefit Assessment 
2.3.1 Known Potential Risks 
Risks of Blood Drawing 
There are small risks to blood sampling, usually some pain/discomfort with the blood stick and 
blood loss. Every effort will be made to avoid additional (to standard of care) sticks for this study 
and will time clinical blood draws to coincide with timed samples, using existing intravenous 
lines when possible. A maximum of 7 plasma PK samples per participant will be collected during 
the treatment and follow-up periods. PK blood samples will be obtained only if laboratory tests 
are being collected per routine medical care. Each sample will be limited to a volume of 250 µL. 
The expected total maximum amount will be no more than 1.75 mL (about 1/3 of a teaspoon). 
Caffeine51 
1. Published literature reports have raised questions regarding possible association between the 
use of methylxanthines, such as caffeine, and the development of necrotizing enterocolitis 
(NEC) in premature neonates, although a causal relationship has not been established.52,53 
2. Caffeine is a central nervous system stimulant and in cases of caffeine overdose, seizures 
have been reported.54 
3. Caffeine increases heart rate and should be used with caution in neonates with 
cardiovascular disease. 
4. Caffeine should be used with caution in neonates with impaired renal or hepatic function. 
 
2.3.2 Known Potential Benefits 
Clinical studies in neonates have demonstrated that caffeine reduces NDI at 18-21 months in 
premature neonates treated for apnea of prematurity.24,25 Preclinical studies in rats have found 
that caffeine offers neuroprotection following perinatal hypoxic-ischemic injury.34,38,39 Therefore, 
a reduction in brain injury and NDI are potential benefits for participants enrolled in the study. 
Conclusions drawn from this study will benefit neonates receiving caffeine in the setting of 
therapeutic hypothermia for HIE in the future through better understanding of dose response 
and characterization of the safety profile of caffeine.  


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2.3.3 Assessment of Potential Risks and Benefits 
Given the high incidence of mortality and NDI in neonates with HIE, we propose that the value 
of the information to be gained in this study outweigh the potential risks of exposure to caffeine. 
We have minimized these potential risks by using a dose of caffeine that is equivalent to the 
dose ranges used on-label for apnea of prematurity in preterm neonates. We will exclude 
neonates with difficult to control seizures (i.e., receiving > 1 anti-epileptic drug [AED]), 
tachycardia (defined as heart rate > 180 beats per minute for > 4 hour), or major congenital 
anomalies, including congenital heart disease. We will collect data on seizures and necrotizing 
enterocolitis as safety events of interest. We will review safety data prior to dose escalation 
between cohorts. 


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3 
OBJECTIVES AND ENDPOINTS 
OBJECTIVES 
ENDPOINTS 
JUSTIFICATION 
FOR ENDPOINTS 
Primary 
 
 
Characterize the pharmacokinetics 
(PK) of caffeine in neonates 
undergoing therapeutic 
hypothermia for hypoxic-ischemic 
encephalopathy (HIE). 
 
 
We will measure serum caffeine 
levels every 12 hours during the 72 
hours of therapeutic hypothermia and 
then daily until 72 hours after the last 
dose.  
 
We will develop a 
population PK model 
using serum caffeine 
measurements. Using 
the final population PK 
model, empirical 
Bayesian estimates of 
clearance (CL), volume 
of distribution (V), half 
life, and exposure 
metrics (e.g. AUC, 
maximum 
concentration) will be 
generated for each 
participant. 
Secondary 
 
 
Characterize the safety of caffeine 
in neonates undergoing therapeutic 
hypothermia for HIE.  
 
We will review adverse events 
through hospital discharge. Seizures 
requiring > 1 AED and NEC will be 
adverse events (AE) of special 
interest.  
Due to the potential for 
decreased seizure 
threshold at high doses 
of caffeine, we will 
focus on the incidence 
of seizure activity as an 
AE of special interest. 
NEC is listed on the 
FDA label for its 
potential association 
with caffeine. 
Preliminary effectiveness of 
caffeine in reducing mortality and 
NDI 
• 
Death prior to discharge 
• 
Abnormal brain MRI findings 
according to the scoring strategy 
used in the NICHD trial5,49: 
o 
Score 0: Normal T2 MRI  
o 
Score 1A: Minimal 
cerebral lesions only with 
involvement of basal 
ganglia, thalamus 
o 
Score 1B: Extensive 
cerebral lesions  
o 
Score 2A: Basal ganglia 
thalamic, anterior or 
posterior limb of internal 
capsule, or         
watershed infarction 
o 
Score 2B: 2A with 
cerebral lesions 
o 
Score 3: Hemispheric 
devastation 
Every neonate with HIE 
who receives 
therapeutic 
hypothermia has a 
brain MRI prior to 
discharge per standard 
of care. MRI findings 
are widely used in 
clinical settings and 
well-validated for the 
prediction of NDI in 
neonates with HIE.  
 
Bayley-III testing is the 
gold-standard for 
assessing NDI in 
infants 18-24 months.  


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OBJECTIVES 
ENDPOINTS 
JUSTIFICATION 
FOR ENDPOINTS 
• 
We will collect cognitive, 
language, and motor scores from 
the Bayley Scales of Infant and 
Toddler Development- Third 
Edition (Bayley-III)55 at 18-24 
months of age to assess 
developmental delay. We will also 
include available data on the 
following outcomes at 18-24 
months: cerebral palsy (using the 
Gross Motor Function 
Classification System), hearing 
impairment requiring hearing aids, 
and blindness.   
Epigenetics  
• 
CpG methylation signatures  
Exploratory aim to 
examine feasibility of 
evaluating differential 
methylation in genes 
encoding for 
cytochrome P450 
enzymes involved in 
caffeine metabolism. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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4 
STUDY DESIGN 
4.1 
Overall Design 
This is a phase I, open-label, dose-escalating PK and safety study of caffeine in neonates with 
HIE undergoing therapeutic hypothermia. There will be two cohorts, with two caffeine dosing 
regimens (see Section 6.1.2, Dosing and Administration). Each cohort will consist of 9 
neonates and the intervention duration will be 48 hours. An interim safety analysis will be 
conducted following the follow-up period in the final cohort 1 participant (see Section 9.4.4, 
Safety Analyses) to assess for safety prior to enrollment in cohort 2. We hypothesize that drug 
clearance will be ≥ 20% lower than expected for gestational age and birth weight and that the 
incidence of adverse events will be similar to those in published trials of therapeutic 
hypothermia. 
4.2 
Scientific Rationale for Study Design 
The PK and safety of caffeine in the setting of HIE are unknown. Given that ischemic injury to 
the liver and kidneys and therapeutic hypothermia likely alters the metabolism and elimination 
(i.e., PK) of caffeine, a phase I study is essential to determine optimal dosing for larger, 
randomized controlled trials to investigate caffeine as a therapeutic agent to reduce NDI 
associated with HIE. This study will provide the necessary first step to design a larger phase 
trial to evaluate the safety and preliminary effectiveness of caffeine in reducing brain injury in 
neonates with HIE. 
 
4.3 
Justification for Dose 
The two dosing regimens are based on available preclinical data in animals which suggest that 
methylxanthine doses of 20 mg/kg reduce hypoxic brain damage.38,39  In one study using a 
hypoxic-ischemic injury model in newborn rats, 20 mg/kg/day of caffeine for three doses 
resulted in a decrease in apoptosis of neuronal cells in the hippocampus and parietal cortex 
compared to controls.39 A second study using a similar model found that a theophylline dose of 
20 mg/kg prior to injury resulted in reduced brain injury compared to higher doses or controls.38 
Furthermore, the FDA caffeine label for apnea of prematurity trial recommends a loading dose 
of 20 mg/kg followed by a daily maintenance dose of 5 mg/kg. The higher maintenance doses in 
cohort 2 of our study is consistent with the dosing range we use to treat apnea of prematurity at 
UNC, and is also consistent with doses used in a large caffeine trial.41  
4.4 
End of Study Definition 
A participant is considered to have completed the study if he or she has completed all phases of 
the study including the neurodevelopmental follow-up visit at 18-24 months, listed as the final 
study assessment in the Schedule of Activities (SoA), Section 1.3. 
 
 
 


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5 
STUDY POPULATION 
5.1 
Inclusion Criteria 
1. Documented informed consent from parent or guardian  
2. ≥ 36 weeks gestational age at birth 
3. Receiving therapeutic hypothermia for a diagnosis of HIE 
4. Intravenous (IV) access 
5. Postnatal age < 24 hours 
 
5.2 
Exclusion Criteria 
1. Receiving > 1 anti-epileptic drug for seizures 
2. Sustained (>4 hours) heart rate > 180 beats per minute 
3. Known major congenital anomaly 
4. Any condition which would make the participant, in the opinion of the investigator, 
unsuitable for the study 
5.3 
 Lifestyle Considerations 
Not applicable. 
5.4 
Screen Failures 
Not applicable. 
 
5.5 
Strategies for Recruitment and Retention 
We anticipate that 18 neonates will be recruited from up to 3 US NICUs, including the University 
of North Carolina at Chapel Hill (UNC) Newborn Critical Care Center (NCCC). Enrollment will 
begin at UNC and expand to other sites, if needed. The decision to provide therapeutic 
hypothermia will be at the discretion of the clinician. A neonate will be eligible for screening and 
enrollment in this study as soon as the decision is made by the clinician to provide therapeutic 
hypothermia for HIE. The parents of neonates undergoing therapeutic hypothermia will be 
approached for enrollment by study coordinators in a timely fashion to ensure that the first dose 
of study drug is given prior to 24 hours postnatal age. For neonates enrolled in the study, 
retention of subjects will be enhanced by close follow-up in the Special Infant Care Clinic, which 
is the standard of care for all neonates undergoing therapeutic hypothermia for HIE at UNC, or 
equivalent follow-up clinic at other sites.  


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6 
STUDY INTERVENTION 
6.1 
Study Intervention(s) Administration 
6.1.1 Study Intervention Description 
The study drug is caffeine citrate injection for intravenous administration, which is commercially 
available and labelled by the FDA for the short term treatment of apnea of prematurity in 
neonates between 28 and <33 weeks gestational age.51 
6.1.2 Dosing and Administration 
Table 3. N and dosing scheme 
N 
Caffeine 
Loading Dose 
Caffeine  
Maintenance Dose 
Cohort 1 
9 
20 mg/kg IV prior to 
24 hours postnatal 
age 
5 mg/kg IV q24 hours x 2 
doses (first dose 24 hours after 
loading dose) 
Cohort 2 
9 
20 mg/kg IV prior to 
24 hours postnatal 
age 
10 mg/kg IV q24 hours x 2 
doses (first dose 24 hours after 
loading dose) 
The first 9 participants will be enrolled in cohort 1 and receive the doses as described in Table 
3. All doses will be intravenous as the presence of a peripheral or central venous catheter is 
standard of care for neonates undergoing therapeutic hypothermia. Caffeine loading doses will 
be administered over 30 minutes and maintenance doses will be administered over 15 minutes 
via an infusion pump, followed by a normal saline flush administered over 5 minutes via an 
infusion pump.  
6.2 
Preparation/Handling/Storage/Accountability 
6.2.1 Acquisition and Accountability 
Detailed information will be part of the MOP.  
6.2.2 Formulation, Appearance, Packaging, and Labeling 
The study drug (caffeine citrate) is the commercially available intravenous formulation. This 
protocol will not specify the brand of product. Detailed information will be part of the MOP.  
6.2.3 Product Storage and Stability 
Detailed information will be part of the MOP. 
6.2.4 Preparation 
The pharmacy at each site will prepare and distribute the study drug and the drug will be 
administered by the bedside nurse.  


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6.3 
Measures to Minimize Bias: Randomization and Blinding 
Not applicable.  
6.4 
Study Intervention Compliance 
Adherence to the protocol will be assessed by use of a participant drug log to be completed by 
the bedside nurse at the time of drug administration. We will record exact start and stop times of 
caffeine dose over the IV pump, as well as start and stop time of flush.  
6.5 
Concomitant Therapy 
All drug and/or treatments are permitted while on study. All concomitant medications and 
treatments will be reported during the study drug administration period.  
6.5.1 Rescue Medicine 
Not applicable. 


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7 
STUDY INTERVENTION DISCONTINUATION AND 
PARTICIPANT DISCONTINUATION/WITHDRAWAL 
7.1 
Discontinuation of Study Intervention 
Participants may be withdrawn from the study at any time. Participants withdrawn from the study 
due to an AE, whether serious or non-serious, must be followed by the investigator until the 
clinical outcome from the AE is determined. Any participant who experiences an AE may be 
withdrawn at any time from the study at the discretion of the investigator. The AE(s) should be 
noted on the appropriate case report forms (CRFs), and the participant’s progress should be 
followed until the AE is resolved or considered stable. If the AE may relate to overdose of study 
treatment, the package insert should be consulted for details of any specific actions to be taken. 
 
Discontinuation from caffeine does not mean discontinuation from the study, and remaining 
study procedures should be completed as indicated by the study protocol.  If a clinically 
significant finding is identified (including, but not limited to changes from baseline) after 
enrollment, the investigator or qualified designee will determine if any change in participant 
management is needed. Any new clinically relevant finding will be reported as an AE. 
7.2 
Participant Discontinuation/Withdrawal from the Study 
The participant’s parent or guardian may withdraw voluntarily from participation in the study at 
any time. The participant’s parent or guardian is not obligated to state the reason for withdrawal. 
The reasons for withdrawal, or failure to provide a reason, must be documented by the 
investigator on the completion/ withdrawal section of the electronic case report form (CRF). We 
will also document missing values in the database for subjects who withdraw from the study.  
 
An investigator may discontinue or withdraw a participant from the study for the following 
reasons: 
 
• 
If any clinical AE, laboratory abnormality, or other medical condition or situation occurs 
such that continued participation in the study would not be in the best interest of the 
participant 
• 
Disease progression which requires discontinuation of the study intervention 
• 
If the participant meets an exclusion criterion (either newly developed or not previously 
recognized) that precludes further study participation (e.g., prescribed a second anti-
epileptic drug for seizures) 
7.3 
Lost to Follow-up 
A participant will be considered lost to follow-up if he or she fails to return for developmental 
follow-up at 18-24 months and is unable to be contacted by the study site staff.  
The following actions must be taken if a participant fails to return to the clinic for a required 
study visit: 
• 
The investigator or coordinator will attempt to contact the participant and reschedule the 
missed visit and counsel the participant’s parent or guardian on the importance of 


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maintaining the assigned visit schedule and ascertain if the parent or guardian wishes to 
and/or should continue in the study. 
• 
Should the participant continue to be unreachable, he or she will be considered to have 
withdrawn from the study with a primary reason of lost to follow-up. 


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8 
STUDY ASSESSMENTS AND PROCEDURES 
8.1 
Study Procedures 
8.1.1 Screening/Baseline  
Research staff will screen for eligibility requirements. After the parent or guardian has provided 
informed consent and after it has been determined that the participant satisfies all inclusion and 
no exclusion criteria, the following evaluations will be recorded in the CRF: 
1. Participant demographics 
a. Maternal race/ethnicity 
b. Maternal age 
c. Inborn/outborn 
d. Infant sex 
e. Gestational age (weeks) 
f. 
Postnatal age (hours) 
2. Neurological exam 
a. Level of consciousness 
i. Hyperalert or irritable 
ii. Lethargic or poorly responsive 
iii. Minimal or no responsiveness 
b. Spontaneous activity 
i. Slightly decreased 
ii. Decreased 
iii. Absent 
c.  Posture 
i. Mild distal flexion 
ii. Distal flexion, complete extension 
iii. Decerebrate 
d. Tone 
i. Hypertonic 
ii. Hypotonic  
iii. Flaccid 
e. Primitive Reflexes 
i. Suck 
1. Normal 
2. Weak or bite 
3. Absent 
4. Unable to assess 
ii. Moro 
1. Low threshold to elicit 
2. Weak or incomplete 
3. Absent 
4. Unable to assess 
f. 
Autonomic 


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i. Pupils 
1. Equal and reactive 
2. Constricted 
3. Dilated and either fixed or sluggishly reactive; asymmetric 
4. Unable to assess 
ii. Respiration 
1. Normal  
2. Periodic breathing 
3. Intubated or ventilated 
3. Birth weight (grams) 
4. Medical history 
a. All Apgar scores (0-10) 
b. Chest compressions in the delivery room (yes/no) 
c. Lowest pH among cord arterial, cord venous, and arterial blood gas taken before 
1 hour of age 
d. Sentinel event, defined as placental abruption, shoulder dystocia, uterine rupture, 
or prolapsed cord 
e. Severity of encephalopathy based on Sarnat staging3 (mild, moderate, or severe) 
f. 
Start time of therapeutic hypothermia 
5. Respiratory support at time of enrollment (room air, oxyhood, nasal cannula/CPAP, or 
mechanical ventilation) and maximum FIO2 exposure during each 24-hour period 
6. Concomitant medications (see Section 6.5) 
7. Laboratory evaluations (see Section 8.2.1) 
8.1.2 Treatment 
The first dose of caffeine must be given prior to 24 hours postnatal age. The day of the first 
caffeine dose will be considered study day 1, with subsequent doses given 24 hours apart on 
study day 2 and 3. During this treatment period, the following evaluations will be recorded in the 
CRF: 
1. Date, time (start time, stop time, and flush time), and dose of each caffeine 
administration 
2. Daily weight (grams) 
3. Highest respiratory support (room air, oxyhood, nasal cannula/CPAP, or mechanical 
ventilation) and maximum FIO2 exposure during each 24-hour period 
4. Concomitant medications (see Section 6.5) 
5. Laboratory evaluations (see Section 8.2.1) 
6. Urine output (in mL/kg/hour) 
7. PK sampling (date and time) (see Section 8.2.2) 
8. Epigenetic sampling (date and time) (see Section 8.2.2) 
9. Clinical events of interest: death, sepsis, disseminated intravascular coagulopathy, 
hypotension, hypertension, hepatic dysfunction, acute kidney injury, persistent 
pulmonary hypertension, and thrombocytopenia.   
10. Adverse events (see Section 8.3), including seizures requiring > 1 AED and NEC 


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11. Head imaging results (including cranial ultrasounds and head computed tomography 
[CT], if obtained per standard of care, and brain MRI) (see Section 8.1.6) 
8.1.3 Follow-up Period 
The following assessments will be recorded in the CRF for the follow-up period (7 days following 
the final dose of caffeine): 
1. Daily weight (grams) 
2. Highest respiratory support (room air, oxyhood, nasal cannula/CPAP, or mechanical 
ventilation) and maximum FIO2 exposure during each 24-hour period 
3. Concomitant medications (see Section 6.5) 
4. Laboratory evaluations (see Section 8.2.1) 
5. Urine output (in mL/kg/hour) 
6. PK sampling (date and time) (see Section 8.2.2) 
7. Epigenetic sampling (date and time) (see Section 8.2.2) 
8. Clinical events of interest: sepsis, disseminated intravascular coagulopathy, 
hypotension, hypertension, hepatic dysfunction, acute kidney injury, persistent 
pulmonary hypertension, and thrombocytopenia. 
9. Adverse events (see Section 8.3), including seizures requiring > 1 AED and NEC 
10. Head imaging results (including cranial ultrasounds and head CT, if obtained per 
standard of care, and brain MRI) (see Section 8.1.6) 
8.1.4 Discharge/Transfer/Death 
At the time of the participant’s discharge from the hospital, transfer, or death, the following 
assessments, when available, will be recorded in the CRF: 
1. Head imaging results (including cranial ultrasounds and head CT, if obtained per 
standard of care, and brain MRI) (see Section 8.1.6) 
2. Hearing screen results (pass or referred) 
3. Neurological exam 
a. Normal 
b. Moderate; any abnormal findings such as mild head lag 
c. Severe; significant neurological abnormalities, such as: 
i. Increased peripheral tone 
ii. Poor suck 
iii. Marked head lag 
4. Surgical procedures during hospitalization 
a. Gastrostomy tube 
b. Tracheostomy 
c. Peritoneal drain 
d. Abdominal laparotomy 
e. Inguinal hernia repair 
f. 
Neurosurgical procedure 
g. Other 
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8.1.5 Final Study Assessment 
At the follow-up visit at 18-24 months, the following assessments will be recorded in the CRF: 
1. Head imaging results (if obtained following discharge) 
2. Neurological exam 
a. Normal 
b. Moderate; any abnormal findings 
c. Severe; significant neurological abnormalities  
3. Bayley-III composite scores 
a. Cognitive 
b. Language 
c. Motor 
4. Gross Motor Function Classification System scores 
5. Medical history 
a. Cerebral palsy diagnosis 
b. Hearing impairment requiring hearing aids 
c. Blindness 
8.1.6 Efficacy Assessments (Preliminary) 
While this early phase trial will not be powered to detect a difference in efficacy compared to our 
historical comparison group, we will assess the preliminary efficacy of caffeine in reducing NDI 
associated with HIE.  This assessment will be based on brain MRI findings during initial 
hospitalization and the final study assessment at 18-24 months in the Special Infant Care Clinic, 
or other follow-up clinic. MRI findings have been shown to be a biomarker of 18-24 month 
neurodevelopmental outcomes in neonates with HIE.49 
Brain MRI 
Per standard of care, all neonates undergoing therapeutic hypothermia receive a non-contrast 
brain MRI, generally at 7-10 postnatal days. For the purposes of this study, a board-certified 
neuroradiologist will review all brain MRIs and assess brain injury using a scoring strategy 
developed for the NICHD Total Body Hypothermia for Neonatal Encephalopathy trial:5,49 
• 
Score 0: Normal T2 MRI  
• 
Score 1A: Minimal cerebral lesions only with involvement of basal ganglia, thalamus 
• 
Score 1B: Extensive cerebral lesions  
• 
Score 2A: Basal ganglia thalamic, anterior or posterior limb of internal capsule, or 
watershed infarction 
• 
Score 2B: 2A with cerebral lesions 
• 
Score 3: Hemispheric devastation 
 
We will record the raw score and dichotomize outcome to normal (0) or abnormal (1). The 
results of the MRI will be disclosed to the neonate’s parent or guardian, along with appropriate 
counseling by a neonatologist.  
 
 
 


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Neurodevelopmental Follow-Up at 18-24 Months 
All neonates enrolled in the study will be followed up in the newborn follow-up clinic and 
screened for developmental delay by a certified examiner at 18-24 months using the Bayley 
Scales of Infant and Toddler Development- Third Edition (Bayley-III).55 We will record the 
composite cognitive, language, and motor scores on the Bayley-III. Additionally, we will record 
whether the infant has hearing impairment requiring hearing aids or blindness at the time of the 
18-24 month visit and assess the presence of cerebral palsy using the Gross Motor Function 
Classification System.  
8.2 
Safety and Other Assessments 
Safety will be assessed through the neonate’s initial hospitalization and it will be assessed by 
frequency and incidence of AEs and SAEs.  
8.2.1 Laboratory Evaluations 
All infants receiving therapeutic hypothermia for HIE receive laboratory evaluations per unit 
guidelines. An example of this lab schedule used at UNC is shown in Table 4.  Following 
completion of therapeutic hypothermia, there are no guidelines at UNC, so additional labs are 
obtained per discretion of the clinician. We will define abnormal lab values using reference 
ranges used in the Pediatric Trials Network.56 We will record the following labs during the 
baseline, treatment, and follow-up periods: 
1. Arterial blood gas: We will record the temperature-corrected pH, PCO2, PaO2, and base 
deficit/excess on blood gases obtained every 12 hours during the treatment period and 
then daily, if available, during the follow-up period. If blood gases are drawn more 
frequently than daily, we will use the blood gas with the lowest pH for that day. If an 
arterial blood gas is not available, we will record venous/capillary gases, if available. 
2. For serum chemistry (chem 10): sodium (mmol/L), potassium (mmol/L), Blood Urea 
Nitrogen (BUN) (mg/dL), creatinine (mg/dL), bicarbonate (mmol/L), calcium (mg/dL), 
chloride (mmol/L), magnesium (mg/dL), phosphorus (mg/dL), and glucose (mg/dL). 
3. For CBC with differential: white blood cell count, hematocrit, and platelet count..  
4. For liver function tests: AST (U/L), ALT (U/L), Albumin (g/dL), Alkaline phosphatase 
(U/L), Gamma-glutamyl Transferase (GGT) (U/L) 
5. For Neobili: Total bilirubin, direct bilirubin (mg/dL).  
6. For coagulation studies: Prothrombin time (PT) (seconds), partial thromboplastin time 
(PTT) (seconds), international normalized ratio (INR), and fibrinogen (mg/dL). 
7. Microbiology: Cultures from sterile body fluids  
 
Table 4. Laboratory Evaluation Schedule for Therapeutic Hypothermia at UNC 


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8.2.2 Special Assays 
PK Samples 
A maximum of 7 plasma PK samples per participant will be collected during the treatment and 
follow-up periods. PK blood samples will be obtained only if laboratory tests are being collected 
per routine medical care. Each blood sample will be limited to a volume of 250 µL. PK samples 
should not be drawn during infusions or during the flush. Caffeine plasma concentrations will be 
measured in the clinical laboratories at each site using a validated bioanalytical assay requiring 
250 µL of whole blood for analysis. Therapeutic drug monitoring of caffeine per routine medical 
care can be performed at any time by the treating physician. This can replace a planned study 
sample. All information obtained from therapeutic drug monitoring of caffeine will be 
incorporated in the final data analysis, even if the time of collection does not follow the study 
collection schedule. 
 
Epigenetic Samples 
Epigenetic samples will be obtained from either leftover cellular components of plasma caffeine 
samples or whole blood samples scavenged from standard of care labs. A maximum of 2 
samples will be collected per participant. The samples will be identified by a code number, and 
all other identifying information will be removed. A targeted epigenetic testing approach 
evaluating CpG methylation on genes encoding for cytochrome P450 enzymes involved in 
caffeine metabolism will be conducted and related to exposure.  Once this testing is completed, 
any remaining epigenetic samples will be destroyed. Caregivers of participants will not be 
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8.3 
Adverse Events and Serious Adverse Events 
8.3.1 Definition of Adverse Events (AE) 
An adverse event (AE) is any untoward medical occurrence in humans, whether or not 
considered drug-related, which occurs during the conduct of a clinical trial. (Any change in 
clinical status, routine labs, x-rays, physical examinations, etc.), that is considered clinically 
significant by the study investigator is considered an AE. 
8.3.2 Definition of Serious Adverse Events (SAE) 
A serious adverse event (SAE) as determined by the investigator is any event that results in any 
of the following outcomes: 
1. Death 
2. Life-threatening AE (“life-threatening” means that the study participant was, in the 
opinion of the investigator or sponsor, at immediate risk of death from the reaction as it 
occurred and required immediate intervention)  
3. Persistent or significant incapacity or substantial disruption of the ability to conduct 
normal life functions  
4. Inpatient hospitalization or prolongation of existing hospitalization 
5. Important medical event that may not result in one of the above outcomes, but may 
jeopardize the health of the study participant or require medical or surgical intervention 
to prevent one of the outcomes listed in the above definition of serious event  
8.3.3 Classification of an Adverse Event 
8.3.3.1  Severity of Event 
The investigator should use the following definitions when assessing severity of an adverse 
event: 
1. MILD: Participant is aware of symptoms or has minor findings but tolerates them well, 
and no or minimal intervention required 
2. MODERATE: Participant experiences enough symptoms or findings to require 
intervention  
3. SEVERE: Participant experiences symptoms or findings that require significant 
intervention 
8.3.3.2  Relationship to Study Intervention 
All adverse events (AEs) must have their relationship to study intervention assessed by the 
clinician who examines and evaluates the participant based on temporal relationship and his/her 
clinical judgment. The degree of certainty about causality will be graded using the categories 
below. In a clinical trial, the study product must always be suspect.  
 
• 
Related – The AE is known to occur with the study intervention, there is a reasonable 
possibility that the study intervention caused the AE, or there is a temporal relationship 
between the study intervention and event. Reasonable possibility means that there is 
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• 
Not Related – There is not a reasonable possibility that the administration of the study 
intervention caused the event, there is no temporal relationship between the study 
intervention and event onset, or an alternate etiology has been established. 
 
The investigator will use the following question when assessing causality of an adverse event to 
study drug, where an affirmative answer designates the event as a suspected adverse reaction: 
Is there a reasonable possibility that the drug caused the event? ‘‘Reasonable possibility’’ 
means that there is evidence to suggest a causal relationship between the drug and the adverse 
event. 
 
8.3.3.3  Expectedness 
The investigator will be responsible for determining whether an adverse event (AE) is expected 
or unexpected.  An AE will be considered unexpected if the nature, severity, or frequency of the 
event is not consistent with the risk information previously described for the study intervention. 
8.3.4 Time Period and Frequency for Event Assessment and Follow-up 
The occurrence of an adverse event (AE) or serious adverse event (SAE) may come to the 
attention of study personnel during the 7 day follow-up period.  
 
All AEs including local and systemic reactions not meeting the criteria for SAEs will be captured 
on the appropriate case report form (CRF). Information to be collected includes event 
description, time of onset, clinician’s assessment of severity, relationship to study product 
(assessed only by those with the training and authority to make a diagnosis), and time of 
resolution/stabilization of the event. All AEs occurring while on study must be documented 
appropriately regardless of relationship. All AEs will be followed to adequate resolution. 
 
Any medical condition that is present at the time that the participant is screened will be 
considered as baseline and not reported as an AE. However, if the study participant’s condition 
deteriorates at any time during the study, it will be recorded as an AE.  
 
Changes in the severity of an AE will be documented to allow an assessment of the duration of 
the event at each level of severity to be performed. AEs characterized as intermittent require 
documentation of onset and duration of each episode. 
The investigator will record all reportable events with start dates occurring any time after 
informed consent is obtained until time of discharge from the initial hospitalization.  
8.3.5 Adverse Event Reporting 
All reportable events as defined above, determined to be an AE based on physical examination, 
laboratory findings, or other means, will be reported in the electronic case report form (e-CRF) 
in the REDCap (Research Electronic Data Capture) database platform. The investigator will 
provide the date of onset and resolution, intensity, frequency, action(s) taken, changes in study 
drug dosing, relationship to study drug, and outcome. 
 


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8.3.6 Serious Adverse Event Reporting 
The study clinician will immediately report to the investigator any serious adverse event, 
whether or not considered study intervention related, including those listed in the protocol or 
investigator brochure and must include an assessment of whether there is a reasonable 
possibility that the study intervention caused the event. Study endpoints that are serious 
adverse events (e.g., all-cause mortality) must be reported in accordance with the protocol 
unless there is evidence suggesting a causal relationship between the study intervention and 
the event (e.g., death from anaphylaxis).  
 
All serious adverse events (SAEs) will be followed until satisfactory resolution or until the 
investigator deems the event to be chronic or the participant is stable.  
 
The investigator will be responsible for notifying the Food and Drug Administration (FDA) of any 
unexpected fatal or life-threatening suspected adverse reaction as soon as possible, but in no 
case later than 7 calendar days after the sponsor's initial receipt of the information.  In addition, 
the sponsor must notify FDA and all participating investigators in an Investigational New Drug 
(IND) safety report of potential serious risks, from clinical trials or any other source, as soon as 
possible, but in no case later than 15 calendar days after the sponsor determines that the 
information qualifies for reporting. 
 
8.3.7 Reporting Events to Participants 
Not applicable 
8.3.8 Events of Special Interest 
1. Seizures will be defined by the receipt of > 1 AED, as we are interested in identifying 
seizures which are difficult to control.  
2. Necrotizing Enterocolitis - Bell Stage II or III57   
8.3.9 Reporting of Pregnancy 
Not applicable 
8.4 
Unanticipated Problems 
8.4.1 Definition of Unanticipated Problems (UP) 
The Office for Human Research Protections (OHRP) considers unanticipated problems 
involving risks to participants or others to include, in general, any incident, experience, or 
outcome that meets all of the following criteria: 
 
• 
Unexpected in terms of nature, severity, or frequency given (a) the research procedures 
that are described in the protocol-related documents, such as the Institutional Review 
Board (IRB)-approved research protocol and informed consent document; and (b) the 
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• 
Related or possibly related to participation in the research (“possibly related” means 
there is a reasonable possibility that the incident, experience, or outcome may have 
been caused by the procedures involved in the research); and 
• 
Suggests that the research places participants or others at a greater risk of harm 
(including physical, psychological, economic, or social harm) than was previously known 
or recognized. 
8.4.2 Unanticipated Problem Reporting 
The investigator will report unanticipated problems (UPs) to the reviewing Institutional Review 
Board (IRB). The UP report will include the following information: 
 
• 
Protocol identifying information: protocol title and number, PI’s name, and the IRB 
project number; 
• 
A detailed description of the event, incident, experience, or outcome;  
• 
An explanation of the basis for determining that the event, incident, experience, or 
outcome represents an UP;  
• 
A description of any changes to the protocol or other corrective actions that have been 
taken or are proposed in response to the UP. 
 
To satisfy the requirement for prompt reporting, UPs will be reported using the following 
timeline:   
 
• 
UPs that are serious adverse events (SAEs) will be reported to the IRB within 7 days of 
the investigator becoming aware of the event.  
• 
Any other UP will be reported to the IRB within 30 days of the investigator becoming 
aware of the problem.  
All UPs should be reported to appropriate institutional officials (as required by an institution’s 
written reporting procedures), the supporting agency head (or designee), and the Office for 
Human Research Protections (OHRP) within 30 days of the IRB’s receipt of the report of the 
problem from the investigator. 
8.4.3 Reporting Unanticipated Problems to Participants 
Not applicable 


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9 
STATISTICAL CONSIDERATIONS 
9.1 
Statistical Hypotheses 
• 
Pharmacokinetics  
We hypothesize that drug clearance will be ≥ 20% lower than expected for gestational age and 
birth weight as a result of HIE and therapeutic hypothermia.  
 
• 
Safety 
We hypothesize that frequency of seizures in both treatment cohorts will be within 20% of 
published results of neonates treated with therapeutic hypothermia in the NICHD Total Body 
Hypothermia for Neonatal Encephalopathy trial.5  
 
• 
Preliminary effectiveness 
We hypothesize that the risk ratio for an abnormal MRI prior to discharge will be favorable, i.e., 
between 0.7 and 1.1 in treated neonates compared to published results of neonates treated with 
therapeutic hypothermia in the NICHD Total Body Hypothermia for Neonatal Encephalopathy 
trial.5 
9.2 
Sample Size Determination 
• 
Pharmacokinetics 
A sample size of 9 neonates in each dosing cohort will be powered (≥ 80%) to target a 95% 
confidence interval within 60% and 140% of the geometric mean estimate of clearance 
(assuming 36% between subject variability in clearance, which is based on existing literature of 
caffeine PK in neonates).58-60   
 
• 
Safety 
The frequency of seizures in the treated group of the NICHD trial was ~40%.5 Estimation of the 
probability of seizures in our study will be based on the combined sample of 18 patients. For 
comparison with historical data, the null hypothesis that the frequency of seizures is 40% will be 
rejected if 11 or more adverse events (in 18 patients) are observed. The event probability will be 
no wider than 21% on each side of the point estimate and this will provide a power of 86%. The 
alternative hypothesis is that the frequency of seizures is >61% or <19% in our study (i.e., > 
21% on either side of the point estimate of 40%).  
• 
Preliminary effectiveness 
This is an exploratory aim and will not be sufficiently powered to detect a significant reduction in 
brain injury on MRI. However, we estimate that there will be a trend toward risk reduction of 
brain injury in enrolled neonates compared to treated neonates in the NICHD trial. 
9.3 
Populations for Analyses 
All participants enrolled and dosed will be included in the safety population and the safety 
analyses. All participants who had at least one interpretable PK sample will be included in the 
PK analysis.  


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9.4 
Statistical Analyses 
9.4.1 General Approach 
Analyses will be presented by treatment cohorts.  There are 2 planned treatment cohorts: 1) 
participants receiving caffeine dosing in Cohort 1; and 2) participants receiving caffeine dosing 
in Cohort 2.   
 
Descriptive statistics 
Descriptive statistics such as number of observations, mean, median, standard deviation, 
standard error, minimum and maximum will be presented by treatment groups for continuous 
variables (such as age, weight, etc.). Other descriptive statistics such as counts, proportions, 
and/or percentages will be presented by group to summarize discrete variables (such as race, 
sex, etc.) 
 
PK analysis plan 
PK parameters will be estimated by population PK approach using nonlinear mixed effects 
modeling in NONMEM (Icon Development Solutions, Elliot City, MD). The influence of 
covariates on PK parameters, such as gestational age, postnatal age, serum creatinine and 
transaminases, oliguria, and concomitant medications will be explored.  
 
Safety  
The number and percent of AEs and SAEs within each cohort will be summarized overall as 
well as by each Medical Dictionary for Regulatory Activities (MedDRA) system organ class and 
preferred term. Laboratory data will be tabulated by dose groups. Summary statistics for 
changes from baseline will be presented.  
 
9.4.2 Analysis of the Primary Endpoint(s) 
• 
Pharmacokinetics 
We will perform a population PK analysis using nonlinear mixed effects methodology 
implemented in the software NONMEM (Icon Development Solutions, Elliot City, MD) to analyze 
caffeine concentration data. We will compare clearance to expected values based on 
gestational age and birth weight.59,60 Since the PK of caffeine is well-described in the literature, 
we will focus our analysis on the effects of HIE and therapeutic hypothermia on caffeine PK. 
Significant covariates (e.g., gestational age, postnatal age, serum creatinine and 
transaminases, oliguria, concomitant medications) will be evaluated using forward addition 
(P<0.05) with backward elimination (P<0.01) approach. 
9.4.3 Analysis of the Secondary Endpoint(s) 
• 
Preliminary Effectiveness 
We will use MRI brain images from enrolled neonates to assess the severity of brain injury 
according to the scoring strategy used in the NICHD trial: 0 (normal MRI), 1A (minimal cerebral 
lesions), 1B (extensive cerebral lesions), 2A (basal ganglia thalamic injury), 2B (2A with cerebral 
lesions), and 3 (hemispheric devastation). We will dichotomize these results into normal and 
abnormal and use logistic regression to compare neonates in cohorts 1 and 2 to treated 
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intervals, adjusting for potential confounders such as severity of encephalopathy and presence 
of seizures.  
 
We will use the composite cognitive, language, and motor scores on the Bayley-III at the 18-24 
month follow-up visit to assess NDI.  We will define NDI as any of the following: composite 
cognitive, language, or motor score < 85, hearing impairment requiring hearing aids, a diagnosis 
of blindness, or GMFCS level ≥ 3. We will use logistic regression to compare neonates in 
cohorts 1 and 2 to treated neonates in the NICHD trial to calculate a risk ratio for NDI with 95% 
confidence intervals.  
 
9.4.4 Safety Analyses 
We will collect information on adverse events (AEs) during and after study drug administration. 
Seizures will be AE of special interest and defined by the receipt of > 1 AED. We will summarize 
AEs by organ system and report descriptive statistics of laboratory values. We will correlate 
caffeine exposure with seizure activity and NEC following the first dose of caffeine. 
Following the follow-up period in the final cohort 1 participant, there will be an interim safety 
analysis performed by an independent safety monitor (ISM) with training in neonatology and 
experience in conducting clinical trials who is not otherwise associated with the study. We will 
halt enrollment during this analysis. If there is > 1 serious adverse events (SAEs) related to the 
drug in any cohort, the study will be temporarily halted for an ad hoc safety review.  
 
9.4.4.1 Clinical Definitions 
1. Sepsis- Positive blood culture and ≥ 7 days of antibiotic treatment 
2. Disseminated Intravascular Coagulopathy: Transfusion of platelets, fresh frozen plasma, 
or cryoprecipitate 
3. Hypotension: Requiring inotrope or vasopressor support 
4. Hypertension: Requiring antihypertensive medication 
5. Hepatic dysfunction: AST > 200 IU/L or ALT > 100 IU/L 
6. Acute Kidney Injury (AKI), stage 1-3 classified using Kidney Disease: Improving Global 
Outcomes (KDIGO) system (Table 5). We will use the highest serum creatinine per 24-
hour period. A participant will be assigned a stage if they meet either serum creatinine or 
urine output criteria listed below.  
Table 5. AKI KDIGO Classification61 
Stage 
Serum Creatinine (SCr) 
Urine Output 
0 
No change in SCr or rise <0.3 mg/dL 
≥ 1.0 mL/kg/hour 
1 
SCr rise ≥ 0.3 mg/dL within 48 hours or SCr rise ≥ 
1.5-1.9 X reference SCra within 7 days 
> 0.5 and ≤ 1 mL/kg/hour  


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2 
SCr rise ≥ 2.0-2.9 X reference SCra 
> 0.3 and ≤ 0.5 mL/kg/hour  
3 
SCr rise ≥ 3 X reference SCra or SCr ≥ 2.5 mg/dL or 
receipt of dialysis 
≤ 0.3 mL/kg/hour  
a Reference SCr will be defined as the lowest previous SCr value 
7. Persistent Pulmonary Hypertension: Requiring inhaled nitric oxide and fraction of 
inspired oxygen >0.50 
8. Thrombocytopenia: Platelet count < 100,000 per µL 
9. Seizures will be defined by the receipt of > 1 AED, as we are interested in identifying 
seizures which are difficult to control.  
10. Necrotizing Enterocolitis - Bell Stage II or III57   
9.4.5 Baseline Descriptive Statistics 
Not applicable.  
9.4.6 Planned Interim Analyses 
Not applicable 
9.4.7 Sub-group Analyses 
Not applicable 
9.4.8 Tabulation of Individual Participant Data 
Individual participant data will be listed by measure and time point. 
9.4.9 Exploratory Analyses 
Epigenetic markers 
We will relate the CpG methylation signatures of genes encoding for cytochrome P450 enzymes 
to caffeine exposure and metabolism.  
 


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10 
SUPPORTING DOCUMENTATION AND OPERATIONAL 
CONSIDERATIONS 
10.1 Regulatory, Ethical, and Study Oversight Considerations 
10.1.1 Informed Consent Process 
10.1.1.1 
Consent/Assent and Other Informational Documents Provided to 
Participants 
Consent forms describing in detail the study intervention, study procedures, and risks are given 
to the participant’s parent or guardian and written documentation of informed consent is 
required prior to starting intervention/administering study intervention.  The following consent 
materials are submitted with this protocol: consent form in English. 
10.1.1.2 
Consent Procedures and Documentation 
Informed consent is a process that is initiated prior to the individual’s parent or guardian 
agreeing to participate in the study and continues throughout the individual’s study participation. 
Consent forms will be Institutional Review Board (IRB)-approved and one of the participant’s 
parents or guardians will be asked to read and review the document. The investigator will 
explain the research study to the parent or guardian and answer any questions that may arise. 
A verbal explanation will be provided in terms suited to the parent’s comprehension of the 
purposes, procedures, and potential risks of the study and of their rights as research 
participants.  The parent or guardian will have the opportunity to carefully review the written 
consent form and ask questions prior to signing. The parent or guardian should have the 
opportunity to discuss the study with their family or surrogates or think about it prior to agreeing 
to participate. The parent or guardian will sign the informed consent document prior to any 
procedures being done specifically for the study. Parents/guardians must be informed that 
participation is voluntary and that they may withdraw their neonate from the study at any time, 
without prejudice. A copy of the informed consent document will be given to the parent or 
guardian for their records. The informed consent process will be conducted and documented in 
the source document (including the date), and the form signed, before the participant undergoes 
any study-specific procedures. The rights and welfare of the participants will be protected by 
emphasizing to the parent or guardian that the quality of their medical care will not be adversely 
affected if they decline to participate in this study. 
10.1.2 Study Discontinuation and Closure 
This study may be temporarily suspended or prematurely terminated if there is sufficient 
reasonable cause.  Written notification, documenting the reason for study suspension or 
termination, will be provided by the suspending or terminating party to study participants, 
investigator, funding agency, the Investigational New Drug (IND) or Investigational Device 
Exemption (IDE) sponsor and regulatory authorities.  If the study is prematurely terminated or 
suspended, the Principal Investigator (PI) will promptly inform study participants, the Institutional 
Review Board (IRB), and sponsor and will provide the reason(s) for the termination or 
suspension.  Study participants will be contacted, as applicable, and be informed of changes to 
study visit schedule. 
  


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Circumstances that may warrant termination or suspension include, but are not limited to: 
• 
Determination of unexpected, significant, or unacceptable risk to participants 
• 
Demonstration of efficacy that would warrant stopping    
• 
Insufficient compliance to protocol requirements 
• 
Data that are not sufficiently complete and/or evaluable 
• 
Determination that the primary endpoint has been met 
• 
Determination of futility 
 
Study may resume once concerns about safety, protocol compliance, and data quality are 
addressed, and satisfy the sponsor, IRB and/or Food and Drug Administration (FDA). 
10.1.3 Confidentiality and Privacy 
Participant confidentiality and privacy is strictly held in trust by the participating investigators, 
their staff, and the sponsor(s) and their interventions. This confidentiality is extended to cover 
testing of biological samples and genetic tests in addition to the clinical information relating to 
participants. Therefore, the study protocol, documentation, data, and all other information 
generated will be held in strict confidence. No information concerning the study or the data will 
be released to any unauthorized third party without prior written approval of the sponsor.  
 
All research activities will be conducted in as private a setting as possible. 
 
The study monitor, other authorized representatives of the sponsor, representatives of the 
Institutional Review Board (IRB), regulatory agencies or pharmaceutical company supplying 
study product may inspect all documents and records required to be maintained by the 
investigator, including but not limited to, medical records (office, clinic, or hospital) and 
pharmacy records for the participants in this study. The clinical study site will permit access to 
such records. 
 
The study participant’s contact information will be securely stored at each clinical site for internal 
use during the study. At the end of the study, all records will continue to be kept in a secure 
location for as long a period as dictated by the reviewing IRB, Institutional policies, or sponsor 
requirements. 
10.1.4 Future Use of Stored Specimens and Data 
Data collected for this study will be analyzed and stored at the University of North Carolina at 
Chapel Hill. During the conduct of the study, an individual participant can choose to withdraw 
consent to have biological specimens stored for future research. However, withdrawal of 
consent with regard to biosample storage may not be possible after the study is completed.  
10.1.5 Key Roles and Study Governance 
Principal Investigator 
Independent Safety Monitor 
Wesley Jackson, MD, MPH 
TBD 
The University of North Carolina at Chapel Hill  
101 Manning Dr. Chapel Hill, NC 27599 
Phone: 984-215-3449 
Email: Wesley.jackson@unc.edu 


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10.1.6 Safety Oversight 
Safety oversight will be under the direction of an ISM with expertise in neonatology and clinical 
trials. The monitor will be independent from the study conduct and free of conflict of interest. 
The monitor will perform a safety analysis following the treatment period in the final cohort 1 
participant and prior to enrollment in cohort 2, or on an ad hoc basis if there is > 1 SAE related 
to the drug in any cohort. 
10.1.7 Clinical Monitoring 
Clinical site monitoring is conducted to ensure that the rights and well-being of trial participants 
are protected, that the reported trial data are accurate, complete, and verifiable, and that the 
conduct of the trial is in compliance with the currently approved protocol/amendment(s), with 
International Conference on Harmonisation Good Clinical Practice (ICH GCP), and with 
applicable regulatory requirement(s). See the clinical monitoring plan (CMP) for more detail.  
 
10.1.8 Quality Assurance and Quality Control 
Each clinical site will perform internal quality management of study conduct, data and biological 
specimen collection, documentation and completion.  An individualized quality management 
plan will be developed to describe a site’s quality management. 
 
Quality control (QC) procedures will be implemented beginning with the data entry system and 
data QC checks that will be run on the database will be generated. Any missing data or data 
anomalies will be communicated to the site(s) for clarification/resolution. 
 
Following written Standard Operating Procedures (SOPs), the monitors will verify that the 
clinical trial is conducted and data are generated and biological specimens are collected, 
documented (recorded), and reported in compliance with the protocol, International Conference 
on Harmonisation Good Clinical Practice (ICH GCP), and applicable regulatory requirements 
(e.g., Good Laboratory Practices (GLP), Good Manufacturing Practices (GMP)).  
 
The investigational site will provide direct access to all trial related sites, source 
data/documents, and reports for the purpose of monitoring and auditing by the sponsor, and 
inspection by local and regulatory authorities. 
10.1.9 Data Handling and Record Keeping 
10.1.9.1 
Data Collection and Management Responsibilities 
Data collection is the responsibility of the clinical trial staff under the supervision of the site 
investigator. Data collection and entry at UNC will be performed by Jennifer Talbert. If additional 
sites are added, the site investigator will designate research staff for data collection and entry. 
Quality review and staff training at all sites will be conducted by research staff from the UNC 
Neonatal-Perinatal Medicine Division. The investigator is responsible for ensuring the accuracy, 
completeness, legibility, and timeliness of the data reported. 
 


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All source documents should be completed in a neat, legible manner to ensure accurate 
interpretation of data.   
 
Hardcopies of the study visit worksheets will be provided for use as source document 
worksheets for recording data for each participant enrolled in the study.  Data recorded in the 
electronic case report form (eCRF) in REDCap derived from source documents should be 
consistent with the data recorded on the source documents.  
 
Clinical data (including adverse events (AEs), concomitant medications, and expected adverse 
reactions data) and clinical laboratory data will be entered into REDCap, a 21 CFR Part 11-
compliant data capture system provided by the North Carolina Translational and Clinical 
Sciences Institute, using a data dictionary. The data system includes password protection and 
internal quality checks, such as automatic range checks, to identify data that appear 
inconsistent, incomplete, or inaccurate. Clinical data will be entered directly from the source 
documents. 
10.1.9.2 
Study Records Retention 
Study documents should be retained for a minimum of 2 years after the last approval of a 
marketing application in an International Conference on Harmonisation (ICH) region and until 
there are no pending or contemplated marketing applications in an ICH region or until at least 2 
years have elapsed since the formal discontinuation of clinical development of the study 
intervention. These documents should be retained for a longer period, however, if required by 
local regulations. No records will be destroyed without the written consent of the sponsor, if 
applicable. It is the responsibility of the sponsor to inform the investigator when these 
documents no longer need to be retained. 
10.1.10 
Protocol Deviations 
A protocol deviation is any noncompliance with the clinical trial protocol, International 
Conference on Harmonisation Good Clinical Practice (ICH GCP), or Manual of Procedures 
(MOP) requirements. The noncompliance may be either on the part of the participant, the 
investigator, or the study site staff. As a result of deviations, corrective actions are to be 
developed by the site and implemented promptly.  
 
These practices are consistent with ICH GCP:  
• 
4.5 Compliance with Protocol, sections 4.5.1, 4.5.2, and 4.5.3  
• 
5.1 Quality Assurance and Quality Control, section 5.1.1  
• 
5.20 Noncompliance, sections 5.20.1, and 5.20.2.  
 
It is the responsibility of the site investigator to use continuous vigilance to identify and report 
deviations within 7 working days of identification of the protocol deviation, or within 7 working 
days of the scheduled protocol-required activity.  Protocol deviations must be sent to the 
reviewing Institutional Review Board (IRB) per their policies. The site investigator is responsible 
for knowing and adhering to the reviewing IRB requirements. Further details about the handling 
of protocol deviations will be included in the MOP. 
10.1.11 
Publication and Data Sharing Policy 
This study will be conducted in accordance with the following publication and data sharing 
policies and regulations: 


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National Institutes of Health (NIH) Public Access Policy, which ensures that the public has 
access to the published results of NIH funded research. It requires scientists to submit final 
peer-reviewed journal manuscripts that arise from NIH funds to the digital archive PubMed 
Central upon acceptance for publication. 
 
This study will comply with the NIH Data Sharing Policy and Policy on the Dissemination of NIH-
Funded Clinical Trial Information and the Clinical Trials Registration and Results Information 
Submission rule. As such, this trial will be registered at ClinicalTrials.gov, and results 
information from this trial will be submitted to ClinicalTrials.gov. In addition, every attempt will be 
made to publish results in peer-reviewed journals.  Data from this study may be requested from 
other researchers 5 years after the completion of the primary endpoint by contacting the PI.  
 
In addition, this study will comply with the NIH Genomic Data Sharing Policy, which applies to all 
NIH-funded research that generates large-scale human or non-human genomic data, as well as 
the use of these data for subsequent research. Large-scale data include genome-wide 
association studies (GWAS), single nucleotide polymorphisms (SNP) arrays, and genome 
sequence, transcriptomic, epigenomic, and gene expression data. 
10.1.12 
Conflict of Interest Policy 
The independence of this study from any actual or perceived influence, such as by the 
pharmaceutical industry, is critical.  Therefore, any actual conflict of interest of persons who 
have a role in the design, conduct, analysis, publication, or any aspect of this trial will be 
disclosed and managed. Furthermore, persons who have a perceived conflict of interest will be 
required to have such conflicts managed in a way that is appropriate to their participation in the 
design and conduct of this trial.  The study leadership has established policies and procedures 
for all study group members to disclose all conflicts of interest and will establish a mechanism 
for the management of all reported dualities of interest. 
10.2 Additional Considerations 
Not applicable 
10.3 Abbreviations 
AE 
Adverse Event 
AED 
Anti-epileptic Drug 
AKI 
Acute Kidney Injury 
ALT 
Alanine Aminotransferase 
AST 
Aspartate Aminotransferase 
AUC 
Area Under the Concentration Time Curve 
BUN 
Blood Urea Nitrogen 
CBC 
Complete Blood Count 
Cc 
Cubic Centimeters 
CFR 
Code of Federal Regulations 
CL 
Clearance 
CMP 
Clinical Monitoring Plan 
CONSORT Consolidated Standards of Reporting Trials 
CPAP 
Continuous Positive Airway Pressure 


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CRF 
Case Report Form 
eCRF 
Electronic Case Report Forms 
CT 
Computed Tomography 
dL 
Deciliter 
EEG 
Electroencephalogram 
FDA 
Food and Drug Administration 
FIO2 
Fraction of Inspired Oxygen 
GA 
Gestational Age 
GCP 
Good Clinical Practice 
GGT 
Gamma-Glutamyl Transferase 
GLP 
Good Laboratory Practices 
GMFCS 
Gross Motor Function Classification System 
GMP 
Good Manufacturing Practices 
GWAS 
Genome-Wide Association Studies 
HIE 
Hypoxic-Ischemic Encephalopathy 
HIPAA 
Health Insurance Portability and Accountability Act  
ICH 
International Conference on Harmonisation  
ICMJE 
International Committee of Medical Journal Editors 
IDE 
Investigational Device Exemption 
IND 
Investigational New Drug Application 
INR 
International Normalized Ratio 
IQR 
Interquartile Range 
IRB 
Institutional Review Board 
ISM 
Independent Safety Monitor 
IU 
International Units 
IV 
Intravenous 
KDIGO 
Kidney Disease: Improving Global Outcomes 
Kg 
Kilogram 
L 
Liter 
MedDRA 
Medical Dictionary for Regulatory Activities 
mg 
Milligram 
mL 
milliliter 
µL 
microliters 
MOP 
Manual of Procedures 
MRI 
Magnetic Resonance Imaging 
NCCC 
Newborn Critical Care Center 
NCT 
National Clinical Trial 
NDI 
Neurodevelopmental Impairment 
NEC 
Necrotizing Enterocolitis 
NICHD 
National Institute of Child Health and Human Development 
NICU 
Neonatal Intensive Care Unit 
NIH  
National Institutes of Health 
NONMEM 
Nonlinear Mixed Effects Modelling 
OHRP 
Office for Human Research Protections 
PaO2 
Partial Pressure of Oxygen in Arterial Blood 
PCO2 
Partial Pressure of Carbon Dioxide 
PI 
Principal Investigator 
PK 
Pharmacokinetics 
PT 
Prothrombin Time 


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PTT 
Partial Thromboplastin Time 
q 
Every 
QA 
Quality Assurance 
QC 
Quality Control 
REDCap 
Research Electronic Database Capture 
SAE 
Serious Adverse Event 
SAP 
Statistical Analysis Plan 
SCr 
Serum Creatinine 
SNP 
Single Nucleotide Polymorphisms 
SOA 
Schedule of Activities 
SOC 
Standard of Care 
SOP 
Standard Operating Procedure 
U 
Units 
UNC 
University of North Carolina at Chapel Hill 
UOP 
Urine Output 
UP 
Unanticipated Problem 
USA 
United States of America 
V 
Distribution 
10.4 Protocol Amendment History 
Version 
Date 
Description of Change  
Brief Rationale 
1.1 
03/11/2019 
Sections 1.3; 3; 7.2; 8.1; 8.2; 9.2; 
9.4.3; 9.4.4; 9.4.6; 10.1.9.1; 10.3 
Suggested revisions from Scientific 
Review Committee 
1.2 
6/26/2019 
Section 6.1.2 – change from 10 to 30 
min administration time for load 
dose; changed version history and 
date in header and title page 
Changed IV caffeine laoding 
dose administration run time 
on pump to 30 minutes to 
match what is in the package 
insert and added infusion 
times for maintenance doses 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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11 
REFERENCES 
 
1. 
Douglas-Escobar M, Weiss MD. Hypoxic-ischemic encephalopathy: a review for the 
clinician. JAMA pediatrics. 2015;169(4):397-403. 
2. 
Laptook AR. Birth Asphyxia and Hypoxic-Ischemic Brain Injury in the Preterm Infant. Clin 
Perinatol. 2016;43(3):529-545. 
3. 
Sarnat HB, Sarnat MS. Neonatal encephalopathy following fetal distress. A clinical and 
electroencephalographic study. Arch Neurol. 1976;33(10):696-705. 
4. 
Gluckman PD, Wyatt JS, Azzopardi D, et al. Selective head cooling with mild systemic 
hypothermia after neonatal encephalopathy: multicentre randomised trial. Lancet. 
2005;365(9460):663-670. 
5. 
Shankaran S, Laptook AR, Ehrenkranz RA, et al. Whole-body hypothermia for neonates 
with hypoxic-ischemic encephalopathy. N Engl J Med. 2005;353(15):1574-1584. 
6. 
Azzopardi DV, Strohm B, Edwards AD, et al. Moderate hypothermia to treat perinatal 
asphyxial encephalopathy. N Engl J Med. 2009;361(14):1349-1358. 
7. 
Zhou WH, Cheng GQ, Shao XM, et al. Selective head cooling with mild systemic 
hypothermia after neonatal hypoxic-ischemic encephalopathy: a multicenter randomized 
controlled trial in China. J Pediatr. 2010;157(3):367-372, 372.e361-363. 
8. 
Simbruner G, Mittal RA, Rohlmann F, Muche R. Systemic hypothermia after neonatal 
encephalopathy: outcomes of neo.nEURO.network RCT. Pediatrics. 2010;126(4):e771-
778. 
9. 
Jacobs SE, Morley CJ, Inder TE, et al. Whole-body hypothermia for term and near-term 
newborns with hypoxic-ischemic encephalopathy: a randomized controlled trial. Arch 
Pediatr Adolesc Med. 2011;165(8):692-700. 
10. 
Tagin MA, Woolcott CG, Vincer MJ, Whyte RK, Stinson DA. Hypothermia for neonatal 
hypoxic ischemic encephalopathy: an updated systematic review and meta-analysis. 
Arch Pediatr Adolesc Med. 2012;166(6):558-566. 
11. 
Nair J, Kumar VHS. Current and Emerging Therapies in the Management of Hypoxic 
Ischemic Encephalopathy in Neonates. Children (Basel, Switzerland). 2018;5(7). 
12. 
Wu YW, Bauer LA, Ballard RA, et al. Erythropoietin for neuroprotection in neonatal 
encephalopathy: safety and pharmacokinetics. Pediatrics. 2012;130(4):683-691. 
13. 
Rogers EE, Bonifacio SL, Glass HC, et al. Erythropoietin and hypothermia for hypoxic-
ischemic encephalopathy. Pediatr Neurol. 2014;51(5):657-662. 
14. 
Roberts JK, Stockmann C, Ward RM, et al. Population Pharmacokinetics of Darbepoetin 
Alfa in Conjunction with Hypothermia for the Treatment of Neonatal Hypoxic-Ischemic 
Encephalopathy. Clin Pharmacokinet. 2015;54(12):1237-1244. 
15. 
Baserga MC, Beachy JC, Roberts JK, et al. Darbepoetin administration to neonates 
undergoing cooling for encephalopathy: a safety and pharmacokinetic trial. Pediatr Res. 
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