Conditions: Klinefelter Syndrome
Keywords: body composition Klinefelter syndrome XXY sex chromosome variation sex chromsome aneuploidy
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 20
Healthy volunteers: no

Brief summary:
This research study in infant males with Klinefelter syndrome (47,XXY) will learn more about body composition (muscle and fat) and male hormones and look at the effect of testosterone shots on body composition. The Investigators know that older boys and men with Klinefelter syndrome often have more fat compared to muscle than adults without Klinefelter syndrome, but we do not know if this difference is present at birth or develops over time. The Investigators will learn if body composition and motor skills are improved with testosterone treatment in infants with Klinefelter syndrome.

Detailed description:

Arms:
arm 1: Testosterone cypionate (200 mg/ml) intramuscular injection arm 2: Subjects will not receive any testosterone during the study period.

Interventions: intervention 1: testosterone cypionate 200mg/ml
Intervention descriptions: intervention 1: Subjects in this group will be randomized to receive testosterone cypionate 200 mg/ml to be given intramuscularly every 4 weeks for a total of 3 doses.

Protocol document:
Prot_SAP_000.pdf: 
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\ 
COMIRB Protocol 
COLORADO MULTIPLE INSTITUTIONAL REVIEW BOARD 
CAMPUS BOX F-490    TELEPHONE:  303-724-1055  Fax:  303-724-0990 
 
Protocol #:  14-1720 
Project Title:  Body Composition in Infants with Klinefelter Syndrome and Effects of Testosterone Treatment 
 
 
 
Principal Investigator:  Shanlee Davis, MD 
Version Date: 3/9/2015 
 
 
 
 
 
  
 
I. Hypotheses and Specific Aims:   
Klinefelter syndrome (KS) affects more than 62,000 children in the United States and is associated with 
motor and psychological impairments in childhood, primary gonadal failure in puberty, and metabolic syndrome 
and related disorders in adolescence and adulthood (1).  Older children and adolescents with KS have been 
shown to have an unfavorable body composition, with a greater adipose tissue to lean muscle ratio that may be 
associated with the increased risk of metabolic syndrome, type 2 diabetes, and cardiovascular-related mortality in 
adults with KS (2-4).  Research suggests these conditions are related to hypogonadism and preventable with tes-
tosterone treatment, although there have been no randomized controlled trials assessing efficacy in reversing un-
favorable body composition once established (5).  Several observations indicate that infants with KS have andro-
gen insufficiency, specifically a higher incidence of underdeveloped genitalia, lower muscle tone, and lower peak 
testosterone levels during the infant hormone surge known as the “mini-puberty.” Furthermore, testosterone is 
often used off-label in infants with KS in the absence of an evidence base (6).  We hypothesize that body compo-
sition in infants with KS is abnormal and associated with lower testosterone levels and, furthermore, can be im-
proved with supplemental testosterone therapy during the normal testosterone surge of infancy.  To test this hy-
pothesis, we will undertake the following specific aims. 
  
1. Specific Aim 1: To assess body composition and gonadal function in infants with KS. We will 
perform air displacement plethysmography (PEA POD) and serum hormone concentrations during 
the mini-puberty period in 20 infant males with a prenatal diagnosis of KS (47,XXY) and compare the 
results to published normal values for male infants of matched age.  
a. Hypothesis 1a: Infants with KS, like older males with KS, will have a higher body fat percent-
age when compared to published normal values.    
b. Hypothesis 1b: Infants with KS will have lower serum testosterone levels compared to pub-
lished normal values.  
c. Hypothesis 1c: Serum testosterone levels will inversely correlate with body fat percentage, 
similar to post-pubertal males with KS.  
2. Specific Aim 2: To determine if a short course of testosterone therapy during the mini-puberty 
period improves body composition in infants with KS. We will randomize half of the infants to re-
ceive intramuscular testosterone at doses commonly used for treatment of underdeveloped genitalia 
in this population and assess body composition as the primary outcome measure. We will compare 
both treated and untreated participants with matched controls from a large local population database. 
Secondary outcome measures will include penile length, muscle tone, and motor development.   
a. Hypothesis 2a: Testosterone treatment will have a favorable effect on body composition, pe-
nile length, muscle tone, and motor development compared to those not treated. 
b. Hypothesis 2b: Untreated KS males will have a higher body fat percentage than matched 
controls from the local population database while treated KS males will not differ from 
matched controls. 
 
II. Background and Significance:  
Klinefelter syndrome (KS) is a common genetic disorder in which males have an extra X chromosome 
(47,XXY).  With a prevalence of 1 out of every 450-650 males, there are assumed to be over 62,000 children in 
the United States with KS, although it is currently underdiagnosed (7,8).  Non-invasive prenatal testing (NIPT) is 
quickly becoming widely available and can reliably identify sex chromosome aneuploidies (9).  This test may soon 


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be offered to all pregnant women as first line screening regardless of age or other risk factors, increasing the pre-
natal diagnosis rate for KS by five to ten-fold.  Expectant parents are faced with decisions, including termination of 
affected fetuses, with very limited evidence-based guidance since the syndrome is understudied, particularly in 
children with a prenatal diagnosis.  Likewise, pediatric healthcare providers have few guidelines for managing 
these children and patterns of care vary greatly (1).  Thus, at a time when prenatal diagnosis of KS will most likely 
greatly increase, a gap exists in our understanding of the natural history, prevention, and treatment of complica-
tions and comorbidities in KS, particularly in infancy and early childhood. 
Adult males with KS have higher fat to lean body mass ratio and higher rates of metabolic syndrome, type 2 
diabetes, and cardiovascular-related mortality (4,5,10-13).  These findings correlate with the degree of androgen 
deficiency and are hypothesized to be secondary to hypogonadism (11,12).  Despite this, there are no random-
ized controlled trials evaluating the efficacy of testosterone in reversing unfavorable body composition, metabolic 
syndrome, or other precursors of cardiovascular disease that are already present.  One cross-sectional study has 
shown a trend toward lower total body fat, cholesterol, and fasting insulin levels in those on testosterone treat-
ment, although these findings were not significant (11).  Recent studies suggest that current approaches to inter-
vention may be too late, as increased body fat mass, percent body fat, waist circumference, insulin resistance, 
and unfavorable lipid profiles are present prior to puberty (2,3).  No studies have looked at body composition in 
infants or toddlers with KS.  Thus a gap exists in determining when increased body fat and decreased muscle 
mass develop. This study would start to address this critical knowledge deficit.  
If hypogonadism is the underlying pathophysiology of an unfavorable body composition in KS and this finding 
is present in pre-pubertal boys, testosterone insufficiency must be present prior to pubertal activation of the hypo-
thalamic-pituitary-gonadal axis.  Infants with KS are known to have lower muscle tone and a higher incidence of 
underdeveloped genitalia in infancy, which suggests that androgen deficiency begins early in life (14,15).  Normal 
male infants have an activation of their hypothalamic-pituitary-gonadal axis with a surge of LH, FSH, and testos-
terone at 2-3 months of age, referred to as the “mini-puberty of infancy.”  The mini-puberty occurs in infants with 
KS, however there is evidence the peak testosterone levels are lower than average (15-17).  Following the infant 
surge, testosterone levels in males with KS are usually normal until mid-puberty, when hormone concentrations 
become characteristic of hypergonadotropic hypogonadism (18-20).  Therefore, as there is evidence to support 
androgen insufficiency in infants with KS, the normal mini-puberty period represents a biologically promising tar-
get for testosterone therapy.  This treatment is currently given to males with micropenis with a widely accepted 
protocol and no significant safety concerns (21).  As around 5% of infants with KS have micropenis and more than 
a third have poor penile growth, infants with KS often receive testosterone treatment for this indication (14,17).  At 
some institutions, this is considered the standard of care for all infants with KS, despite a lack of scientific evi-
dence to support this practice (22).  The only study investigating testosterone treatment in KS infants is a retro-
spective observational study published in 2013 that identified neurodevelopmental benefit for KS boys with a his-
tory of testosterone treatment (23).  A gap currently exists in the potential of short and long-term outcomes of tes-
tosterone treatment in infants with KS, and this study will explore body composition and motor development as 
short term outcome measures.            
Body composition is affected by testosterone, with inverse correlations between serum testosterone levels 
and percent body fat in multiple populations including adult men with KS and normal neonates. Testosterone 
treatment has been shown to favorably alter body composition in males with hypogonadotropic hypogonadism 
(24).  Body composition is a clinically meaningful outcome measure of testosterone treatment, as unfavorable 
body composition may have direct implications in infancy and childhood, contributing to the motor delays and de-
creased strength, endurance, and athletic ability seen in KS.  Furthermore, an unfavorable body composition pro-
file in infancy may be a surrogate marker for an altered metabolism contributing to adult diseases, such as the 
metabolic syndrome, fatty liver disease and type 2 diabetes (12).  This study aims to address the question of 
whether body composition in infants with KS is a measurable and modifiable outcome of testosterone during the 
expected mini-puberty of infancy. 
 
III. Preliminary Studies/Progress Report:   
Previous experience with this population. Early in her career the PI worked as a research assistant with Dr. 
Nicole Tartaglia (co-investigator) collecting data and interacting with hundreds of patients with various sex chro-
mosome aneuploidies and their families.  Select descriptive data from this work derived from parent report and 
physical exams of children with KS includes a high prevalence of hypotonia (65%), poor coordination (66%), and 
low endurance (47%).    
Children’s Hospital Colorado eXtraordinarY Kids Clinic. The eXtraordinarY Kids Clinic is a multidisciplinary 
clinic, nationally unique to CHCO, that provides comprehensive clinical care for children with X & Y chromosome 


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disorders.  Dr. Nicole Tartaglia (co-investigator) is the Medical Director of the clinic and has an extensive publica-
tion record in this population.  Dr. Phil Zeitler (co-investigator) is the primary endocrinologist for the clinic and has 
expertise in the endocrinological manifestations in KS, as well as extensive research in the areas of body compo-
sition, insulin resistance, and obesity-related comorbidities in children.  The clinic has been an excellent base for 
recruitment into clinical-translational research with over 950 patient visits (~65% with KS).  Due to the nationally-
recognized expertise in KS, the clinic’s genetic counselor receives over 25 calls annually from expectant parents 
seeking more information and research opportunities. Descriptive data from boys with KS < 5 years of age partici-
pating in an ongoing observational study revealed 88% had hypotonia and 62% had delays in motor development.  
More strikingly, 38% had received testosterone injections as infants despite the lack of evidence to support this 
practice.    
Local expertise in infant body composition. Several active studies on campus currently utilize the PEA POD 
for measurement of body composition in infants.  Collaboration with researchers who have expertise in this field, 
including Regina Reynolds, MD (co-investigator), has been important in development of this protocol.  Additional-
ly, Dana Dabelea, PhD, has offered a de-identified data set for a large population-based healthy cohort of 5 
month olds (Healthy Start Study) to serve as a resource for matched normal values. These local resources make 
this the ideal setting for a successful study of body composition in KS infants.  
Other relationships to help with recruitment. Perinatal genetic counselors at University Hospital and Kaiser 
have agreed to assist with identifying potential study subjects with a prenatal diagnosis of KS.  In addition, AXYS, 
the parent support group for all sex chromosome aneuploidies with over 7,800 contacts, fully supports of recruit-
ment for this study. 
 
IV. Research Methods 
 
A.  Outcome Measure(s):   
The primary outcome measure will be body composition (percent fat mass) as determined by the PEA POD. Sec-
ondary outcome measures will be 1) pre-treatment serum and urine gonadotropins and serum testosterone levels, 
2) assessment of tone and motor abilities by an occupational therapist blinded to treatment assignment, and 3) 
stretched penile length. 
 
B. Description of Population to be Enrolled:   
Twenty male infants with KS (karyotype 47,XXY) will be recruited to participate in this pilot study.  The age of the 
infants was chosen 1) to allow assessment of gonadal status during the expected mini-puberty period of infancy, 
2) to allow the final assessment to be completed before the infant is 10kg, as this is the upper weight limit for the 
PEA POD. 
Inclusion criteria: Male infants 6-15 weeks of age with 47,XXY karyotype.    
Exclusion criteria:  Gestational age at birth <36 weeks, birth weight <5%ile or >95% for gestational age, histo-
ry of thrombosis in a first degree relative, and exposure to androgen therapy outside of the study protocol. 
 
Subjects will be recruited through (1) the eXtraordinarY Kids Clinic at Children’s Hospital Colorado, (2) Obstetrics 
and genetic counseling departments at University Hospital and other perinatal centers in the Denver area, and (3) 
Outreach from KS-related support groups including postings on websites and in newsletters. 
 
C. Study Design and Research Methods   
Overall study design.  This is a pilot study of body composition and testicular function in infants with KS com-
pared to published norms for males by age (Specific Aim 1), followed by a randomized trial of a short course of 
testosterone therapy with evaluation of change in body composition and motor development (Specific Aim 2).  
Total study duration for each individual subject is 10-12 weeks.    
 
 
BASELINE EXAM, PEA 
POD & LABORATORY 
ASSESSMENTS at 6-15 
weeks of age (n=20)
Testosterone 25mg IM 
q-4 weeks x 3 (n=10) 
No testosterone     
(n=10) 
EXAM, PEA POD and 
BLINDED TONE AS-
SESSMENT at 5-6 
months of age  
(n=20)


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Study Timeline and Procedures. 
 
Week
Activity
Subjects
Personnel
Location
1 
Baseline study visit 
 
Consent  
 
Medical History 
 
Physical Examination 
 
OT evaluation 
 
PEA POD assessment 
 
Blood and urine collection 
 
Randomization 
All 
 
PI or RA 
PI 
PI 
Blinded OT 
PI/Co-investigator 
CTRC RN 
Research Team 
Pediatric CTRC 
1 
Testosterone injection #1  
Treatment only 
 
Pediatric CTRC 
2 
Phone call to parents 
All 
PI or RA 
N/A 
4 
Testosterone injection #2 
Treatment only 
 
Pediatric CTRC  
5 
Phone call to parents 
All 
PI or RA 
N/A 
8 
Testosterone injection #3 
Treatment only 
 
Pediatric CTRC 
10-12 
Final study visit 
 
Medical History 
 
Physical Examination 
 
OT evaluation 

PEA POD assessment
All 
 
PI 
Blinded Peds Endo 
Blinded OT 
PI/Co-investigator 
Pediatric CTRC 
 
Screening. Potential subjects will be screened for inclusion and exclusion criteria via phone conversation prior to 
the first study visit.  The consent document will be provided to the parents and discussed with a member of the 
research team.  If the subject qualifies and parents are interested in participating in this research study, the initial 
study visit will be scheduled between 6 and 15 weeks of age.    
 
Baseline study visit: This initial visit will occur at 6-15 weeks of age and will take approximately 3 hours. 
 
Randomization. At the conclusion of the baseline study visit, subjects will be randomized to 1) Testosterone 
treatment or 2) no pharmacologic intervention.  A large opaque manila envelope will contain smaller sealed enve-
lopes each of which hold a single piece of paper with the letter “T” (testosterone treatment) or “X” (no treatment) 
written on them.  We will randomize in blocks of 10.  A member of the research team will pull out a single enve-
lope that will contain the group to which the subject will be assigned.  This study will not be blinded or include a 
placebo intervention due to ethical limitations of giving placebo injections.  However, all outcomes that are not 
entirely objective (physical exam, OT assessment) will be performed by a study staff member who is blinded to 
the participants treatment assignment.  The parents of participants will be counselled not to disclose their random-
ization status to blinded study personnel.          
 
Injection visits (treatment group only.) These will be arranged to be done at the outpatient CTRC at CHCO.  If it is 
not feasible for the subject to return to CHCO for injections #2 and #3, the parents will be given the option to do 
the injection at home. The parent will be taught by a medical professional on the study team how to draw up and 
administer the intramuscular injection.  Teaching families to administer home injections is standard practice for 
clinical care. Given the highly motivated population being enrolled in this study, it is reasonable to provide this 
option for families who live a long distance from Children’s Hospital Colorado.       
  
Phone calls to parents: This will serve to assess for adverse events as well as facilitate subject retention.  
 
Final study visit. The final study visit will occur 10-12 weeks after the baseline study visit (2-4 weeks after receiv-
ing the final testosterone injection for those in the treatment group).  Estimated time for this visit is approximately 
3 hours. At that time, subjects will be offered the opportunity to be seen clinically (outside of the research proto-
col) in the eXtraordinarY Kids clinic for a full developmental assessment.    
 


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Patient participation:  Parents/patients may choose to stop participation at any point in the study.  Mandatory pa-
tient discontinuation criteria will include any serious adverse event related to the study protocol including but not 
limited to thrombosis, hemorrhagic event, and anaphylaxis.    
 
D.   Description, Risks and Justification of Procedures and Data Collection Tools: 
Medical history. Maternal and infant medical history, medications, therapies or other interventions, and infant 
feeding method will be documented. No anticipated risk to subject. See data collection sheet. 
 
Physical examination.  Length and weight will be obtained by CTRC nurses. A comprehensive physical exam will 
be performed by a pediatric endocrinologist blinded to the treatment arms.  Stretched penile length, tanner stag-
ing, and testicular size by Prader orchiometer will be done by a pediatric endocrinologist blinded to the treatment 
arms.  No anticipated risk to subject.  
 
PEA POD.  The PEA POD provides a reliable, non-invasive, quantitative assessment of fat mass and non-fat 
mass utilizing air-displacement plethysmograph technology in infants weighing less than 10 kilograms (25). This 
instrument has been validated with other methods of assessing body composition, such as deuterium dilution and 
dual-energy X-ray absorptiometry, and normative values for healthy, term, average-gestational age males are 
published from birth through 6 months (26). The PEA POD is safe and comfortable for infants and takes less than 
10 minutes to perform.  This body composition assessment method was chosen for its low risk to the patient 
compared to more intensive and occasionally invasive measures of body composition.  This assessment will be 
performed by the PI with a blinded study investigator (Dr. Reynolds and/or CTRC RN).   
     
Alberta Infant Motor Scale (AIMS). The AIMS is a performance-based and norm-referenced measure of infant 
gross motor maturation from birth to 18 months.  It is intended to evaluate gross motor development over repeat-
ed assessments and has good reliability and predictive validity for later gross motor development (27,28).  In a 
systematic review of neurodevelopmental tests, the AIMS had the best psychometric properties and clinical utility 
(29). The assessment will be administered by an OT (co-investigator) at the baseline and the final visit. The OT 
will remain blinded to the treatment arms. There is no anticipated risk to with this assessment.    
 
Peabody Developmental Motor Scales 2 (PDMS-2). This is a standardized assessment tool for infant develop-
ment and includes six subtests to assess gross and fine motor scales from birth to 5 years. It is one of the most 
common tools for discriminating normal from abnormal infant motor development (30).  This instrument was cho-
sen as it is more broad assessment of motor development compared to the AIMS, has normative reference data, 
and strongly correlates with other motor assessments.  This will be administered by an OT (co-investigator) at 
both the baseline and the final visit. The OT will remain blinded to the treatment arms. . Change in raw scores will 
be evaluated in both treatment and non-treatment groups.  There are no anticipated risks to the subject with this 
assessment. 
 
Movement Assessment of Infants (MAI).  This standardized instrument quantifies motor behaviors and contains 
four different domains: tone, primitive reflexes, automatic reactions, and volitional movement (31). We will be us-
ing the first domain only (tone) for the objective assessment of muscle tone. This will be administered by an OT 
(co-investigator) at both the baseline and the final visit.  The OT will remain blinded to the treatment arms. There 
are no anticipated risks to the subject with this assessment.      
 
Laboratory assessments. Venipuncture will be performed at the initial study visit for measurement of luteinizing 
hormone (LH), follicle stimulating hormone (FSH), total testosterone (TT), anti-mullerian hormone (AMH), inhibin 
B, and leptin.  The serum will be spun, frozen, and saved in Endocrine Departmental freezers. These samples will 
be sent to the lab of collaborator, Dr. Najiba Lahlou in Paris, France for analysis of all the above biomarkers. Dr. 
Lahlou has a special interest in sex chromosome aneuploidy and has published one of the few studies examining 
gonadotropins and markers of testicular function during the mini-puberty period in KS (16). Urine collection bag 
will be placed for measurement of urine gonadotropins in the lab of Nanette Santoro, MD in the Department of 
Obstetrics and Gynecology at the University of Colorado.  Laboratory assessments will be obtained in the morn-
ing if possible.   
 
Testosterone treatment.  Subjects randomized to testosterone treatment will receive testosterone cypionate (200 
mg/mL) 25 mg given via intramuscular injection every 4 weeks for three doses.  This treatment dosing and dura-


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tion is accepted practice for treatment of micropenis in this age group without reported side effects (21). The po-
tential minor side effects of testosterone therapy include inflammation and/or pain at the site of injection, hyper-
sensitivity reactions, acne, and adrenarche.  Serious side effects are not anticipated, however androgen therapy 
at higher doses and/or for longer duration has been associated with venous thromboembolus, water retention, 
and priapism.  Given the short duration and low dose of therapy, no routine laboratory screening will be done.  
Families of subjects will be contacted one week following the initial assessment (and first dose of testosterone for 
those being treated) to assess for any concerns the family may have.   
   
E.   Potential Scientific Problems:   
Recruitment of the study population within the age window specified will be the primary challenge. However, the 
research team is well-positioned with the nationally recognized, eXtraordinarY Kids Clinic and relationships with 
other referral sources.  If recruitment goals are not being met after the first year, inclusion/exclusion criteria and 
recruitment efforts will be evaluated. Other potential scientific problems include the many contributing factors in-
fluencing body composition.  However, these will be minimized due to the young age of the children enrolled.  We 
plan to exclude those born <36 weeks gestation and those born small or large for gestational age.  We will collect 
data on factors that could potentially contribute to body composition, including maternal BMI, weight gain during 
pregnancy, maternal results on oral glucose tolerance testing, birth weight and gestational age, infant feeding 
method, and physical therapy interventions.  We will control for any factors that are significantly different between 
the treatment and non-treatment groups.  In addition, given introduction of solid foods alters body composition, we 
will provide parents with the current American Academy of Pediatrics recommendations for solely breastfeeding 
until 6 months of age.       
 
F.   Data Analysis Plan:   
As a pilot study, feasibility will be assessed both qualitatively and quantitatively including enrollment and comple-
tion numbers, reasons for declining participation and/or withdrawing from participation, protocol challenges, and 
reasons for any data points that could not be collected.  
 
For continuous outcomes, frequency distributions for each variable of interest at baseline and final study visit will 
be generated and examined for normality assumptions, and if not met, nonparametric equivalents will be used. 
Outliers and missing data will be evaluated on an individual basis, with checking of source documentation to en-
sure the value is correct. Due to the small study numbers, outliers will not be excluded and any missing data will 
be treated as missing without imputation.  
 
Summary statistics for demographic variables, covariates known to affect body composition, hormone concentra-
tions, and outcomes at baseline will be generated and reported as means and standard deviation (or nonparamet-
ric equivalent). For the primary outcome, change in percent body fat z-scores will be compared between groups 
using Welch’s two-sided, two-tailed t-test with an a priori level of significance set at 5%. Secondary outcomes in-
cluding percent fat mass, absolute measures of body composition parameters (fat mass, fat free mass, total 
mass), stretched penile length z-scores (and absolute penile lengths), other anthropometric measures, and motor 
skills scores will be analyzed in a similar fashion. As a secondary analysis, percent body fat at the final study visit 
will be compared between the treated group, untreated group, and data from normal local male controls at a me-
dian of 5 months of age using ANOVA followed by between group t-tests. No corrections for multiple comparisons 
are planned given the pilot nature of the study. All parent-reported adverse events and significant adverse events 
in the treatment group will be reported. No comparisons will be made between treated and untreated groups as 
these data are not being collected in the group not receiving treatment. 
 
G.  Summarize Knowledge to be Gained:   
The results of this study will be important in 1) assessing the feasibility of recruitment and enrollment of this popu-
lation into a larger clinical trial, and 2) determining the change in chosen outcome measures (body composition, 
motor development) following testosterone treatment to allow development of a statistical plan for a larger, multi-
center study with both short and longer-term outcomes.  The results of this study will impact clinical practice as 
currently up to 1/3 of infants with KS are treated with testosterone without existing research identifying the bene-
fits or potential harm of the variable doses, durations, and administration methods.  If testosterone therapy posi-
tively effects body composition and motor development in infants, this therapy may eventually be shown to pre-
vent the insulin resistance and increased cardiovascular morbidity and mortality in this population.  Furthermore, 
results of this work may be generalizable beyond KS in understanding the understudied relationship of hy-


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pogonadism, body composition, and insulin resistance characteristic of obese boys, a problem of increasing sig-
nificance secondary to the pediatric obesity epidemic. 
 
 H. References: 
         
1. 
Radicioni, Ferlin, et al. Consensus statement on diagnosis and clinical management of Klinefelter 
syndrome. J Endocrinol Invest. 2010;33(11):839-850. 
2. 
Bardsley, Falkner, et al. Insulin resistance and metabolic syndrome in prepubertal boys with Klinefelter 
syndrome. Acta Paediatr. 2011;100(6):866-870. 
3. 
Aksglaede, Molgaard, et al. Normal bone mineral content but unfavourable muscle/fat ratio in 
Klinefelter syndrome. Arch Dis Child. 2008;93(1):30-34. 
4. 
Jiang-Feng, Hong-Li, et al. Prevalence and risk factors of diabetes in patients with Klinefelter syndrome: a 
longitudinal observational study. Fertil Steril. 2012;98(5):1331-1335. 
5. 
Bojesen, Host, et al. Klinefelter's syndrome, type 2 diabetes and the metabolic syndrome: the impact of 
body composition. Mol Hum Reprod. 2010;16(6):396-401. 
6. 
Fennoy. Testosterone and the child (0-12 years) with Klinefelter syndrome (47XXY): a review. Acta 
Paediatr. 2011;100(6):846-850. 
7. 
Bojesen, Juul, et al. Prenatal and postnatal prevalence of Klinefelter syndrome: a national registry study. 
J Clin Endocrinol Metab. 2003;88(2):622-626. 
8. 
Herlihy, Halliday, et al. The prevalence and diagnosis rates of Klinefelter syndrome: an Australian 
comparison. Med J Aust. 2011;194(1):24-28. 
9. 
Lo, Cori, et al. Noninvasive prenatal testing. Obstet Gynecol Surv. 2014;69(2):89-99. 
10. 
Andersen, Bojesen, et al. Left ventricular dysfunction in Klinefelter syndrome is associated to insulin 
resistance, abdominal adiposity and hypogonadism. Clin Endocrinol (Oxf). 2008;69(5):785-791. 
11. 
Bojesen, Kristensen, et al. The metabolic syndrome is frequent in Klinefelter's syndrome and is 
associated with abdominal obesity and hypogonadism. Diabetes Care. 2006;29(7):1591-1598. 
12. 
Gravholt, Jensen, et al. Body composition, metabolic syndrome and type 2 diabetes in Klinefelter 
syndrome. Acta Paediatr. 2011;100(6):871-877. 
13. 
Swerdlow, Higgins, et al. Mortality in patients with Klinefelter syndrome in Britain: a cohort study. J Clin 
Endocrinol Metab. 2005;90(12):6516-6522. 
14. 
Ratcliffe, Butler, et al. Edinburgh study of growth and development of children with sex chromosome 
abnormalities. IV. Birth Defects Orig Artic Ser. 1990;26(4):1-44. 
15. 
Lahlou, Fennoy, et al. Clinical and hormonal status of infants with nonmosaic XXY karyotype. Acta 
Paediatr. 2011;100(6):824-829. 
16. 
Lahlou, Fennoy, et al. Inhibin B and anti-Mullerian hormone, but not testosterone levels, are normal in 
infants with nonmosaic Klinefelter syndrome. J Clin Endocrinol Metab. 2004;89(4):1864-1868. 
17. 
Ross, Samango-Sprouse, et al. Early androgen deficiency in infants and young boys with 47,XXY 
Klinefelter syndrome. Horm Res. 2005;64(1):39-45. 
18. 
Aksglaede, Skakkebaek, et al. Clinical and biological parameters in 166 boys, adolescents and adults with 
nonmosaic Klinefelter syndrome: a Copenhagen experience. Acta Paediatr. 2011;100(6):793-806. 
19. 
Salbenblatt, Bender, et al. Pituitary-gonadal function in Klinefelter syndrome before and during puberty. 
Pediatr Res. 1985;19(1):82-86. 
20. 
Wikstrom, Dunkel, et al. Are adolescent boys with Klinefelter syndrome androgen deficient? A 
longitudinal study of Finnish 47,XXY boys. Pediatr Res. 2006;59(6):854-859. 
21. 
Carrillo. Disorders of Sexual Differentiation. In: Lifshitz, ed. Pediatric Endocrinology. Vol 2. Fifth ed. New 
York, NY: Informa Healthcare USA; 2007. 
22. 
Wosnitzer, Paduch. Endocrinological issues and hormonal manipulation in children and men with 
Klinefelter syndrome. Am J Med Genet C Semin Med Genet. 2013;163C(1):16-26. 


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23. 
Samango-Sprouse, Sadeghin, et al. Positive effects of short course androgen therapy on the 
neurodevelopmental outcome in boys with 47,XXY syndrome at 36 and 72 months of age. Am J Med 
Genet A. 2013;161A(3):501-508. 
24. 
Blouin, Boivin, et al. Androgens and body fat distribution. J Steroid Biochem Mol Biol. 2008;108(3-5):272-
280. 
25. 
Ma, Yao, et al. Validation of a new pediatric air-displacement plethysmograph for assessing body 
composition in infants. Am J Clin Nutr. 2004;79(4):653-660. 
26. 
Fields, Gilchrist, et al. Longitudinal body composition data in exclusively breast-fed infants: a multicenter 
study. Obesity (Silver Spring). 2011;19(9):1887-1891. 
27. 
Darrah, Piper, et al. Assessment of gross motor skills of at-risk infants: predictive validity of the Alberta 
Infant Motor Scale. Dev Med Child Neurol. 1998;40(7):485-491. 
28. 
Snyder, Eason, et al. Concurrent validity and reliability of the Alberta Infant Motor Scale in infants at 
dual risk for motor delays. Phys Occup Ther Pediatr. 2008;28(3):267-282. 
29. 
Spittle, Doyle, et al. A systematic review of the clinimetric properties of neuromotor assessments for 
preterm infants during the first year of life. Dev Med Child Neurol. 2008;50(4):254-266. 
30. 
Provost, Heimerl, et al. Concurrent validity of the Bayley Scales of Infant Development II Motor Scale 
and the Peabody Developmental Motor Scales-2 in children with developmental delays. Pediatr Phys 
Ther. 2004;16(3):149-156. 
31. 
Harris, Swanson, et al. Predictive validity of the "Movement Assessment of Infants". J Dev Behav Pediatr. 
1984;5(6):336-342. 
 

ICF_001.pdf: 
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Initials______
Principal Investigator:
Shanlee Davis, MD
COMIRB No:  14-1720
Version Date: 6/8/2015
Study Title:  Body Composition in Infants with Klinefelter Syndrome and Effects of 
Testosterone Treatment
You have been asked to decide for your child whether he should be in a research study.  
This form provides you with information about the study. A member of the research 
team will describe this study to you and answer all of your questions. Please read the 
information below and ask questions about anything you don’t understand before 
deciding whether or not to take part. 
Why is this study being done?
This study plans to learn more about the amount of muscle and fat (body composition), 
motor development, and male hormones in infant boys with Klinefelter syndrome 
(47,XXY). We know that older boys and men with Klinefelter syndrome have more fat 
compared to muscle, but we do not know if this is true at birth or develops over time.  
We also want to know if muscle mass plays a role in development of motor skills.  
Finally, we would like to learn how the male hormone testosterone changes the amount 
of muscle and fat and motor skills development.     
Your child is being asked to be in this research study because he is an infant with a 
diagnosis of Klinefelter syndrome (karyotype 47,XXY). 
Other people in this study
Up to 20 people from your area will participate in the study. 
What happens if my child joins this study?
If your child joins the study, he will have the first study visit between 6-15 weeks of age.  
At the end of that visit, half of the children will be assigned to get a testosterone shot 
once a month for 3 months while the other half will not receive testosterone.  At the end 
of the three months, the final study visit will take place for all participants, whether or not 
they received the shots.  The total length of the study is about 3 months. 
The first visit and last visits will occur at Children’s Hospital Colorado and include: 

You answering some questions about your child 

a physical exam of your child including measurements of your child’s body and 
penis 

a play-based exam of how your child’s muscles work

measurement of the amount of muscle and fat by a type of scale called the PEA 
POD 
COMIRB
APPROVED
For Use
16-Jun-2015
12-Feb-2016


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
blood draw (first visit only) to test levels of hormones in the blood

urine collected by a bag (first visit only) to test levels of hormones in the urine
In between the first and last visits:

Half of children will receive a total of 3 testosterone shots, while the other half of 
the children will not receive any shots. 

If your child is in the group to receive shots, he will get a shot in his thigh once a 
month for three months, starting with the first visit.

All parents will get two calls from a research team member to check in during the 
study.  The first will be one week after their initial visit and the second about a 
month later.
Week
Study Activity
Which subjects
1
Baseline study visit

Consent 

History

Physical Examination

Play-based developmental evaluation

PEA POD measurement

Blood and urine collection

Randomization to treatment or not
All
1
Testosterone injection #1 
Treatment group only
2
Phone call to parents
All
4
Testosterone injection #2
Treatment group only
5
Phone call to parents
All
8
Testosterone injection #3
Treatment group only
10-12
Final study visit

History

Physical Examination

Play-based developmental evaluation

PEA POD measurement
All
How we decide which study group you will be in
This study will have 2 different groups of infants, one group will receive testosterone 
shots and the other will not.  You cannot choose which group your child will be in. To 
decide which group your child will be in, we will use a method of chance.  This method 
is like flipping a coin or rolling dice.  We will open an envelope together at the end of the 
first study visit that tells us which group he will be in.  
You will know what study group your child is in, but not all the study team will
You will know what study group your child is in.  Dr. Davis will also know, but all of the 
other study team members will not know.  This information needs to be kept secret so 
that the study results are based on scientific findings, not peoples’ opinions. We will ask 
you not to tell any of the other people on the study team about which group your child is 
in.


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What are the possible discomforts or risks?
Part of the physical exam and PEA POD measurement will require all clothes to be 
removed.  This could cause your baby to be uncomfortable but should not cause pain. 
The test itself takes about a minute and we usually do it twice.  There are no known 
risks with the PEA POD.  
In this study we will need to get about 2 teaspoons of blood from your child. We will get 
blood by putting a needle into one of his veins and letting the blood flow into a glass 
tube.  He may feel some pain when the needle goes into the vein.  A day or two later, 
your child may have a small bruise where the needle went under the skin.
The testosterone shots are given into the muscle in your child’s thigh.  A day or two 
later, your child may have a small bruise, swelling, or redness of the area where the 
needle went under the skin.  Skin rashes near where the needle went in or pimples on 
the infants face can happen sometimes.  The testosterone may make your child’s penis 
grow and could cause him to have erections.  Rare side effects of testosterone, such as 
blood clots, difficulty clotting, increased red blood cells, and anaphylaxis or allergic 
reaction have not been reported with the low doses we are using in this study, however 
may be possible.  It is also possible that testosterone shots have other risks that are 
unknown at this time. 
The play-based exam of your child’s muscles and development may show 
abnormalities. If your child is found to have abnormalities on this test we may 
recommend further evaluation for your child.  This may be distressful to you as the 
parents.  Any additional evaluation would be your decision as the parents and would not 
be required of the study. 
There is a risk that people outside of the research team will see your child’s research 
information.  We will do all that we can to protect this information, but it cannot be 
guaranteed.
The study may include risks that are unknown at this time. 
What are the possible benefits of the study?
This study is designed for us to learn more about how testosterone affects infants with 
Klinefelter syndrome.  We are looking at the amount of muscle and fat, and at your 
baby’s motor skills.  However, there is no guarantee that your child’s health will improve 
if you join this study.  Also, there could be risks to being in this study. These risks are 
described in the section describing the discomforts or risks.
Are there alternative treatments? 
Testosterone shots are currently only recommended for infants with a small penis 
(called micropenis).  Infants with micropenis can get testosterone shots in the same 
dose we are giving in this study.  If your child has micropenis, but is not chosen to be in 


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the study group that receives testosterone shots, you can still choose to do these shots 
after the study is completed.  If your child does not have micropenis, there are not 
alternative medical treatments for infants with Klinefelter syndrome. Your child may 
continue to receive any therapies or other treatment prescribed by his primary doctor 
during the study, just not testosterone or testosterone-related products.  
You should talk to your doctor about your choices.  Make sure you understand all of 
your choices before you decide to have your child take part in this study.  Your child 
may leave this study and still have these other choices available. 
Who is paying for this study? 
This research is being paid for by a grant from the Colorado Clinical and Translational 
Science Institute.
Will my child be paid for being in the study?  
You/your child will be paid $20 for the first and last visit of this study. This will add up to 
a total of $40 if your child completes both of the visits. If your child leaves the study 
early, or if we have to take your child out of the study, you will be paid only for the visits 
completed. 
If you live more than 100 miles from Children’s Hospital Colorado, some travel 
expenses (hotel stay or mileage reimbursement) may be eligible for reimbursement up 
to a maximum of $100. 
It is important to know that payment for participation in a study is taxable income.
Will I have to pay for anything?
It will not cost you anything to be in this study. You will not have to pay for any medical 
care that is part of this study, including tests and the study drug.  You or your insurance 
company will have to pay for other medical expenses that occur during the time your 
child is in the study, including diagnosis and treatment of any complications.
Is my child’s participation voluntary?
Taking part in this study is voluntary.  You have the right to choose not to have your 
child take part in this study.  If you choose to have your child take part, you have the 
right to stop at any time.  If you refuse or decide to withdraw later, your child will not lose 
any benefits or rights to which he is entitled. 
If your child leaves this study, he will still receive normal medical care.  The only 
medical care that your child will lose is the medical care he is getting as part of this 
study.  Your child might be able to get that same kind of medical care outside of the 
study.  Ask your study doctor. 


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If there are any new findings during the study that may affect whether you want your 
child to continue to take part, you will be told about them.
Can my child be removed from this study? 
The study doctor may decide to stop your child’s participation without your permission if 
the study doctor thinks that being in the study may cause your child harm, or for any 
other reason. 
What happens if I am injured or hurt during the study? 
If you have an injury while you are in this study, you should call Dr. Davis immediately. 
Her phone number is 720-777-6073. 
We will arrange to get you medical care if you have an injury that is caused by this 
research.  However, you or your insurance company will have to pay for that care. 
Who do I call if I have questions?
The researcher carrying out this study is Dr. Shanlee Davis. You may ask any questions 
you have now. If you have questions, concerns, or complaints later, you may call Dr. 
Davis at 720-777-6073. You will be given a copy of this form to keep.  
You may have questions about your rights as someone in this study. You can call Dr. 
Davis with questions.  You can also call the responsible Institutional Review Board 
(COMIRB).  You can call them at 303-724-1055. 
You may also contact a Research Advocate at the Clinical Translational Research 
Center. The number there is 720-848-6662. 
A description of this clinical trial will be available on http://www.Clinical Trials.gov, as 
required by U.S. Law. This Web site will not include information that can identify you. At 
most, the Web site will include a summary of the results. You can search this Web site 
at any time.
Who will see my research information?
The University of Colorado Denver (UCD) and its affiliated hospital(s) have rules to 
protect information about your child.  Federal and state laws including the Health 
Insurance Portability and Accountability Act (HIPAA) also protect your child’s privacy.   
This part of the consent form tells you what information about your child may be 
collected in this study and who might see or use it.  The institutions involved in this 
study include: 
University of Colorado Denver


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Children’s Hospital Colorado (CHCO)
CHCO shares a medical record system with the Barbara Davis Center and 
PedsConnect; therefore it is also possible that your child’s information could be viewed 
by healthcare professionals at these organizations. 
We cannot do this study without your permission to see, use and give out your child’s 
information.  You do not have to give us this permission.  If you do not, then your child 
may not join this study.  
We will see, use and disclose your child’s information only as described in this form and 
in our Notice of Privacy Practices; however, people outside the UCD and its affiliate 
hospitals may not be covered by this obligation.
We will do everything we can to maintain the confidentiality of your child’s personal 
information but confidentiality cannot be guaranteed. 
The use and disclosure of your information has no time limit.  You can cancel your 
permission to use and disclose your child’s information at any time by writing to the 
study’s Principal Investigator (PI), at the name and address listed below.  If you do 
cancel your permission to use and disclose your information, your child’s part in this 
study will end and no further information about your child will be collected.  Your 
cancellation would not affect information already collected in this study.  
Shanlee Davis, MD
Children’s Hospital Colorado
13123 East 16th Ave B265
Aurora, CO 80045
Both the research records that identify your child and the consent form signed by you 
may be looked at by others who have a legal right to see that information, such as:  

Federal offices such as the Food and Drug Administration (FDA) and the Office 
of Human Research Protections (OHRP) that protect research subjects like you.

People at the Colorado Multiple Institutional Review Board (COMIRB)

The study doctor and the rest of the study team.

Officials at the institution where the research is conducted and officials at other 
institutions involved in this study who are in charge of making sure that we follow 
all of the rules for research
We might talk about this research study at meetings.  We might also print the results of 
this research study in relevant journals.  But we will always keep the names of the 
research subjects, like your child, private. 


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You have the right to request access to your child’s personal health information from the 
Investigator. To ensure proper evaluation of test results, your access to these study 
results may not be allowed until after the study is completed.
The investigator (or staff acting on behalf of the investigator) will use your information 
for the research outlined in this consent form. They will also make some of the following 
health information about you collected in this study available to:
Le Laboratoire de Biologie Hormonale (blood samples only)
The laboratory of Dr. Nanette Santoro at the University of Colorado Denver
Inclusion in the research study involves the use of your child’s genetic information 
(Klinefelter syndrome).  Your child’s genetic information will be known by the members 
of the study team.   
Information about you that will be seen, collected, used and disclosed in this 
study:

Name and Demographic Information (age, sex, ethnicity, address, phone 
number, etc.

Portions of your child’s previous and current Medical Records that are relevant to 
this study, including but not limited to Diagnosis(es), History and Physical, laboratory 
studies, radiology studies, procedure results

Research Visit and Research Test records
What happens to data, blood, and urine that are collected in this study? 
Scientists at the University of Colorado Denver and the hospitals involved in this study 
work to find the causes and cures of disease.  The data, blood and urine specimens 
collected from your child during this study are important to this study and to future 
research.  If your child joins this study:

The data, blood, or urine specimens given by your child to the investigators for 
this research no longer belong to you or your child.  

Both the investigators and any sponsor of this research may study your data, 
blood, or urine specimens collected from your child.

If data, blood, or urine specimens are in a form that identifies your child, UCD or 
the hospitals involved in this study may use them for future research only with 
your consent or Institutional Review Board (IRB) approval.

Any product or idea created by the researchers working on this study will not 
belong to you or your child.

There is no plan for you or your child to receive any financial benefit from the 
creation, use or sale of such a product or idea. 


C o m bi n e d Bi o m e di c al C o n s e nt a n d S e p ar at e M ai n a n d O pti o n al HI P A A  a ut h ori z ati o n s
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I niti al s _ _ _ _ _ _
A gr e e m e nt t o b e i n t hi s st u d y a n d u s e m y  c hil d’ s d at a
I h a v e r e a d t hi s p a p er a b o ut t h e st u d y or it w a s r e a d t o m e.  I u n d er st a n d t h e p o s si bl e 
ri s k s a n d b e n efit s of t hi s st u d y.  I u n d er st a n d a n d a ut h ori z e t h e a c c e s s, u s e a n d 
di s cl o s ur e of m y c hil d’ s i nf or m ati o n a s st at e d i n t hi s f or m.  I k n o w t h at b ei n g i n t hi s st u d y 
i s v ol u nt ar y.  I c h o o s e t o h a v e m y c hil d b e i n t hi s st u d y: I will g et a si g n e d a n d d at e d 
c o p y of t hi s c o n s e nt f or m.
C hil d’ s N a m e: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
P ar e nt’ s Si g n at ur e:
D at e:
_ _ _ _ _ _
Pri nt N a m e:
C o n s e nt f or m e x pl ai n e d b y:
D at e:
Pri nt N a m e:
Wit n e s s Si g n at ur e: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _  
D at e _ _ _ _ _ _ _ _ _ _ _
    (if a p pli c a bl e)
Pri nt N a m e:
Wit n e s s of Si g n at ur e

Wit n e s s of c o n s e nt pr o c e s s

I n v e sti g at or: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _  
D at e: _ _ _ _ _ _ _ _ _ _
I n v e sti g at or m u st si g n wit hi n 3 0 d a y s