Novel Epigenetic Biomarker for Prematurity Related Neurodevelopmental Disorders in Childhood

Study Overview
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Brief Summary
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Preterms are early exposed to a stressful environment (i.e. excessive sensory stimulation and paucity of parental contact) with subsequent detrimental effects on brain maturation and neurodevelopmental outcomes. In contrast, early interventions seem to reduce stress exposure and promote neurodevelopment. The brain functional plasticity in response to environmental experiences can be partly attributed to changes in DNA methylation. In this context, LINE-1 (L1) promoter (18% of human genome) methylation/demethylation has been associated with L1 somatic mobilization in the brain genomes, contributing to experience-driven brain plasticity; this mechanism being deregulated in important neurological disease. This study aims at identifying and characterizing the role of L1 DNA repeats as a novel biomarker to predict long-term neurodevelopmental outcome in preterm infants. In addition, the study's secondary goal will be to define a preventive approach, based on early intervention strategies, for improving long-term neurodevelopmental outcomes.

Detailed Description
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Around 25-50% of very preterm infants suffer from neurodevelopmental delays (motor, cognitive and behavioral problems), which are most likely related to brain micro-structural defects and impaired neuronal maturation and connectivity. These alterations in brain maturation occurring during the neonatal period may be implicated in long-term neurobehavioral disorders later experienced by preterm babies. There is increasing evidence that also stressful events (excessive sensory stimulation, paucity of parental contact and painful procedures) experienced in the Neonatal Intensive Care Unit (NICU) by preterm neonates can affect neurodevelopment through epigenetic mechanisms. The brain is a genomic mosaic, owing to somatic mutations that arise throughout development. It is already established that mobile genetic elements, including LINE-1 (L1), are one source of somatic mosaicism, inducing copy number variations in neural genome. Environmental experiences can drive brain plasticity at a molecular level, with changes in DNA methylation. In particular, L1 promoter methylation/demethylation is already associated with L1 mobilization in the brain genomes and its deregulation is linked with important neurological diseases. A preliminary study has shown the correlation between L1 promoter methylation levels and preterm birth. In addition, maternal care during early life has been reported to drive variability in L1 mobilization and methylation of the neural hippocampal genome in mice models. Several studies have reported how individualized developmental care in the NICU can ameliorate preterm infants' medical outcome and subsequent neurodevelopment. More recently, early intervention (EI) strategies based on parental training and multisensory stimulation, such as infant massage and visual stimulation, have been demonstrated to enhance child's neurodevelopment. These programs have the greatest potential to reduce environmental stress in preterms, promoting brain plasticity, optimizing dyadic interaction and ameliorating neurodevelopmental outcomes.

Official Title
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Structural Variations of the Neural Genome as Prognostic Biomarkers for Prematurity Related Neurodevelopmental Disorders in Childhood

Conditions
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Premature Birth

Intervention / Treatment
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* Behavioral: Early Intervention


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Gestational age at birth between 24+0 and 32+6 weeks Mothers age over 18 years Good comprehension of the Italian language Written informed consent signed by both parents Exclusion Criteria: Infants with major genetic disorders and malformations Parents declined study participation Single-parent family Parents with obvious cognitive or psychiatric disorders and drug addiction

Ages Eligible for Study
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Minimum Age: 24 Weeks
Maximum Age: 32 Weeks

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Intervention Model: Single Group Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Early Intervention<br>All the enrolled preterm infants are assigned to receive the early neurodevelopmental intervention during the NICU stay. | Behavioral: Early Intervention<br>* The early intervention (EI) is delivered during the NICU stay. It is a multisensory intervention which consists in three parts: parental training, massage therapy and visual interaction. The EI is first focused on parental training, according to PremieStart Protocol, in order to train parents to: recognize signs of infant stress and alert-available behavior through the identification of infant's behavioral states; adopt principles of graded stimulation; sustain infant's attention and respond to infant's cues; optimize interactions and avoid overwhelming infants through facilitation strategies. The program is held in eight main sessions and one additional post-discharge session. In addition, parents are trained and invited to daily promote preterm baby massage therapy and visual interaction (visual fixation/tracking and visual attention).<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| L1 Promoter Methylation Levels on Biological Materials | Epigenetic analysis is performed on biological materials: cord blood sample and buccal swab at birth, peripheral blood sample and buccal swab at NICU discharge/term equivalent age, buccal swab collected during the follow up assessment at 12 and 24 months of corrected age. | Up to 24 months corrected age | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Conventional and advanced brain Magnetic Resonance Imaging (MRI) | Evaluation of brain development and maturation | Term equivalent age, approximately 40 weeks postmenstrual age | 
| Neurological Examination | Hammersmith Neonatal Neurological Examination (HNNE) | Term equivalent age, approximately 40 weeks postmenstrual age | 
| General Movements Examination | Prechtl's Qualitative Assessment of General Movements | Term equivalent age, approximately 40 weeks postmenstrual age | 
| Visual Assessment | Neonatal Visual Assessment Battery developed by Ricci et al. The assessment evaluates the following items: ocular spontaneous motility, ability to fix and follow a target, reaction to colour, visual acuity and visual attention at distance. | Term equivalent age, approximately 40 weeks postmenstrual age | 
| Neurodevelopmental Outcome | Children development assessed using the Griffiths Mental Development Scales, performed at 12 and 24 months of corrected age. Mean score is 100. General score has a Standard deviation of 12 and sub scales have a Standard Deviation of 16. Higher scores indicate better outcomes. | Up to 24 months corrected age | 
| Behavioral Outcome | Children behavior assessed using the Child Behavior Checklist (CBCL). It is a parent report form to screen for emotional, behavioral and social problems. Lower scores indicate better outcomes. A T score above 75 is considered pathological while a T score between 65 and 74 is considered borderline. | 24 months corrected age | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Parent-infant interaction, Premature Birth, DNA Methylation, L1 Elements, Epigenometics, Early Intervention, Brain Development, Neurodevelopment, Massage therapy, Visual interaction