Conditions: Chlorhexidine Allergy Infection Rash
Keywords: chlorhexidine safety bath rash infant
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 10
Healthy volunteers: no

Brief summary:
Literature provides overwhelming evidence supporting the use of chlorhexidine gluconate (CHG) a rapid onset, broad spectrum, topical antiseptic for reducing healthcare-associated infections (HAIs). CHG is believed to be superior to other forms of antiseptics because, when it is applied to the skin surface, it leaves a lasting residue on the skin. CHG has been shown to be well tolerated in patients 2 months of age and older. However there is limited evidence to support the use of topically applied CHG in infants less than 2 months of age because of potential safety concerns in this population. The purpose of this study will be to describe the safety of bi-weekly CHG baths in a sample of Newborn Intensive Care Unit (NICU) and pediatric Cardiac Intensive Care Unit (CICU) patients by measuring the incidence of skin problems and CHG blood levels.

Detailed description:
Evidence overwhelmingly supports the use of Chlorhexidine Gluconate (CHG) a rapid onset, broad spectrum, topical antiseptic for reducing Healthcare-associated Infections (HAIs). CHG provides prolonged protection against both gram-positive and gram-negative organisms. Reports indicate CHG is well tolerated in patients greater than two months of age. However, due to safety concerns, there is limited evidence to support the use of topically applied CHG in infants less than 2 months of age.

The purpose of this Phase I Clinical (pilot) study is to describe the safety of bi-weekly CHG baths in a sample of 50 Newborn Intensive Care Unit (NICU) and pediatric Cardiac Intensive Care Unit (CICU) patients, (36 weeks PMA or older, less than 2 months of age or 48 weeks PMA and with a CVC), by measuring the incidence of skin problems and CHG blood levels. CHG baths will be performed every Monday and Thursday during the day shift, for up to 12 weeks post enrollment or until the CVC is removed or the patient is discharged.

Chlorhexidine Gluconate bathing cloths are marketed for peri-operative skin preparation. However, daily CHG baths are a common practice in ICUs around the nation because of its proven method for preventing HAIs in patients \> 2 months of age and older. Furthermore, CHG use for skin antisepsis has become a widely accepted practice, and it is now part of the Centers for Disease Control and Prevention (CDC) CVC maintenance bundle for use in patients greater than 2 months of age, and a recommendation to use with caution in infants \< 2 months of age.

Hypothesis 1:CHG will be safe for use in a sample of infants 36 weeks PMA or older, and less than 2 months of age (48 weeks PMA) with a CVC as evidenced by an adverse event rate less than 10%.

Hypothesis 2: Twice weekly CHG baths do not lead to rising (cumulative) CHG blood levels, LFTs (AST/ALT) and Serum Creatinine over time in a sample of infants 36 weeks PMA or older, and less than 2 months of age (48 weeks PMA) with a CVC..

Arms:
arm 1: All subjects will receive a bath twice a week with 2% CHG bathing cloths. The baths will be followed by blood sampling for CHG levels prior to initiation of baths and every Friday for the duration of study participation. The study team will monitor the infant's skin for evidence of untoward lesions prior to the first bath and every 12 hours during the course of the study. CHG blood levels will be monitored for associated adverse events and accumulation.

Interventions: intervention 1: Chlorhexidine gluconate
Intervention descriptions: intervention 1: Bi-weekly chlorhexidine baths

Protocol document:
Prot_SAP_000.pdf: 
 
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Pilot Study: Safety of Chlorhexidine (CHG) Baths in Patients Less Than 2 Months of Age 
 
Introduction  
 
Literature provides overwhelming evidence supporting the use of chlorhexidine gluconate (CHG) a rapid 
onset, broad spectrum, topical antiseptic for reducing healthcare-associated infections (HAIs).  CHG is 
believed to be superior to other forms of antiseptics because, when it is applied to the skin surface, it 
leaves a lasting residue on the skin.  This residue cannot readily be removed with alcohol, a commonly 
used antiseptic during lab draws and frequently performed invasive procedures, and thus CHG provides 
prolonged protection against both gram-positive and gram-negative organisms. Additionally, reports 
indicate CHG is well tolerated in patients greater than 2 months of age.  However, there is limited 
evidence to support the use of topically applied CHG in infants less than 2 months of age, or 48 weeks’ 
postmenstrual age (PMA), because of potential safety concerns in this population.  
 
The purpose of this investigation will be to describe the safety of bi-weekly CHG baths in a sample of 
Newborn Intensive Care Unit (NICU) and pediatric Cardiac Intensive Care Unit (CICU) patients less than 
2 months of age by measuring the incidence of skin problems, other adverse events and CHG blood 
levels.   
 
Definition. In this proposal 2 months of age is equivalent to 2 months’ post-term gestation, or 48 weeks 
PMA.  All other references to age will be presented in the number of week’s PMA.     
 
Background and Significance  
 
HAI Prevention and CHG. Decreasing HAIs has been a long-standing challenge for health care 
institutions and a primary focus for governing bodies such as The Centers for Medicare and Medicaid 
Services (CMS), The Healthcare Infection Control Practices Advisory Committee (HICPAC), and The 
Joint Commission (TJC).  There have been many national, statewide and multi-centered collaborative 
studies with the main focus being the reduction of HAIs, specifically central line associated blood stream 
infections (CLABSIs). Additionally, significant research has also been dedicated to finding products and 
developing practices that will help to minimize and maybe even eliminate the occurrence of HAIs.  
 
One product that has been frequently studied and widely published is CHG.  CHG is used for skin 
antisepsis before surgery, before central venous catheter (CVC) insertion, and for routine patient 
bathing.  The majority of published evidence overwhelmingly supports CHG use for skin antisepsis.  The 
use of CHG on the skin leads to significant reductions in colonization by organisms including methicillin 
resistant staphylococcus aureus (MRSA) and vancomycin resistant enterococcus (VRE), among 
others. Multiple studies have been conducted in pediatric and adult intensive care units comparing CHG 
against other products.  One study (Mimoz, 2007) found CHG to be superior over povidone-iodine for 
CVC insertion and routine CVC care (dressing changes).  Other studies, (Vernon, 2006; Bleasdale, 2007; 
Milstone, 2013) compared daily bathing with 2% CHG cloths against standard soap and water baths.  All 
of these studies found significant decreases in bloodstream infections (BSIs) and/or skin colonization 
when skin asepsis was performed through daily bathing with CHG.  Also, Lee et al (2013) looked at CHG 
blood concentrations in a small sample (12 subjects) of PICU patients undergoing daily bathing with 2% 
CHG-impregnated bathing cloths.  All study participants were greater than 2 months of age.  Blood 
samples were taken on (approximately) days 1, 4, 7 and weekly after daily CHG bathing had been 
initiated.  Sixty-nine subjects had serum CHG levels of less than 4.5, 9 had CHG levels between 4.5-16.9, 
and 3 had CHG levels greater than 17.  While these investigators found that CHG was absorbed into the 
blood streams of the subjects, there was no evidence of accumulation of CHG with repeated exposures 
over time.  According to the investigators, when the high serum levels were repeated, half of the tests 
showed no evidence of CHG in the bloodstream.  


 
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In response to these studies and others, CHG use for skin antisepsis has become a widely accepted 
practice, and it is now part of the Centers for Disease Control and Prevention (CDC) CVC maintenance 
bundle for patients greater than 2 months of age.  
 
CHG use in Young Infants. Mature, intact skin is a natural barrier to a host of infectious organisms.  Skin 
that is free of these infectious organisms is necessary for invasive procedures like surgery and the 
insertion of CVCs.  However, the permeable and fragile skin of the preterm infant and those infants less 
than 2 months of age remain problematic to healthcare providers.  Even once commonly used products 
lead to problems; for instance, povidone-iodine solutions have been noted to alter thyroid function when 
absorbed, and isopropyl-alcohol solutions have led to extensive skin injury including burns. (Harpin and 
Rutter 1982) 
 
Although evidence suggests that CHG is safe and efficacious to use in adult and pediatric patients greater 
than 2 months of age, many pediatric providers remain cautious about its use in infants less than 2 months 
of age.  This caution stems from 2 landmark events.  The first occurred when the topically applied 
antibacterial agent hexachlorophane (HCP) was used.  HCP reportedly caused neurotoxicity in newborns 
and animals, generating fear amongst healthcare providers (Powell et al 1973).  The second occurred 
when the US Food and Drug Administration (FDA) revised the labeling on CHG products as “not 
recommended for use in infants under 2 months of age” in response to the problems with HCP.  As a 
result, there has been limited studies’ investigating the use of CHG in infants less than 2 months of age.  
 
Infection Control in NICU and CICU. Despite multiple infection prevention initiatives including yearly 
mandatory education through Net learning, staff education days and skills days, the number of CLABSIs 
remains problematic in Boston Children’s Hospital (BCH) intensive care units. Since 2012, the NICU at 
Boston Children’s Hospital has experienced 6 CLABSIs and the pediatric Cardiac ICU has had 21. Of 
these reported CLABSIs, 40% (11/27) occurred in infants less than 2 months of age. Furthermore, these 
HAIs may be directly related to increased morbidity and mortality for these hospitalized infants.  
 
More recently, the FDA revised the labeling of CHG to “use with care in premature infants and infants 
under 2 months of age” (FDA Medwatch-internet, last revised 2012; O’Grady et al 2011). Additionally, 
HAIs remain a significant problem in this patient population.  Moreover anecdotal and published reports 
suggest that some caring for these young infants are using CHG without data to support its safety.  
 
Review of Literature. Our review of studies examining use of CHG in young infants has yielded more 
questions than answers.  In one study by Cowen et al (1979), 34 infants were bathed with 4% Hibitane 
CHG (also called Hibiscrub), followed by a water rinse.  They concluded that CHG levels were present in 
the blood of term and preterm newborns that were exposed to 4% Hibitane CHG baths. However, the 
investigators hypothesized that many blood samples were contaminated since CHG cannot be washed off 
with alcohol that is used on the skin before obtaining the blood samples.  Another, Aggert et al (1981) 
studied both term and preterm infants exposed to 1% CHG solution for neonatal cord care. The umbilical 
cord was treated with 1% CHG and 3% zinc oxide powders.  This treatment was repeated every 4 hours 
for a minimum of 9 days.  Blood samples were obtained on approximately days 5 and 9 of the study, 
when other lab work was being obtained.  The results demonstrated greater absorption of CHG in the 
preterm population, heightening concern for use of CHG products in preterm infants.  
 
In 2009, Tamma et al surveyed 100 United States NICUs about CHG use in their units. Of the 90 NICUs 
that responded, 55 NICUs reported using CHG (61%), with the most frequent use being CVC dressing 
changes (78%).  A surprising 49 % (27/55) did not report limiting CHG use for weight, gestational age or 
chronological age.  Also 28 of the NICUs reported skin reactions like erythema and burns resulting from 
CHG use.  More specifically, burns were primarily reported to have occurred when CHG was used on 


 
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infants weighing less than 1500 grams (13/15; 76%).    
 
In 2012, Popovich studied CHG concentrations on the skin after daily CHG bathing compared to 
microbial density on the skin.  The CHG levels on the skin did not show evidence of accumulation after 
repeated exposure through bathing and levels returned to baseline within 24-hours after exposure. Though 
of note, Popovich also concluded that the presence of untoward organisms on the skin was inhibited up to 
3 days later, and was significantly lower than patients who were bathed with soap and water.   
 
Untoward, Adverse Events Associated with CHG. While chlorhexidine has become a widely utilized 
antiseptic, it is not used without risk. With the assistance of Alison Clapp MLIS, the hospital librarian, an 
extensive literature search for untoward or adverse events associated with CHG revealed a number of 
concerning documents citing problems including mild skin irritation, Allergic Contact Dermatitis (ACD) 
and anaphylaxis. Most notably though, the more serious reactions were related from direct exposure to 
multiple products containing CHG and CHG impregnated devices (Khoo & Oziemski, 2010; Kutzscher, 
2012), or direct contact between the CHG product and the mucous membranes of the individual. (Khan et 
al, 2011). In general, there were no serious events associated with CHG bathing cloths, with most reports 
citing only mild skin reactions. (Vernon et al, 2006; Bleasdale et al, 2007; Darmstadt et al, 2007; Sankar 
et al, 2009; Milstone et al, 2013). 
 
Purpose Statement 
 
Daily CHG baths are a proven method for preventing HAIs in patients greater than 2 months of age and 
older.  However, CHG has been shown to be absorbed through the skin of premature and term infants and 
safe CHG bloodstream levels are not known. Thus the use of CHG in infants less than 2 months of age 
remains controversial.  
 
Like many ICUs across the nation, the ICUs at Boston Children’s Hospital have been using CHG on a 
limited basis for CVC insertion and CVC dressing changes on all babies greater than 28 weeks PMA for 
almost 2 years.  During this time, we have not observed any untoward effects to the skin’s surface. 
Though despite our best efforts, HAIs remain problematic, and thus we remain reluctant to expand the use 
to daily CHG baths without a better understanding of the risks and benefits. In effort to secure the benefit 
of CHG baths while minimizing risk of bloodstream absorption, our study team has elected to investigate 
the safety of twice-weekly 2% CHG baths in a sample of newborns (36 weeks PMA or older, less than 2 
months of age or 48 weeks PMA, with a CVC). This study will examine the safety of twice weekly CHG 
baths and provide data to support a larger study that will examine efficacy.  The research questions to be 
answered by this study are as follows: 
 
Research Question 1: 
Are twice weekly CHG baths safe for use in a sample of infants 36 weeks PMA or older, and less 
than 2 months of age (48 weeks PMA) with a CVC? 
Hypothesis 1: 
CHG will be safe for use in a sample of infants 36 weeks PMA or older, and less than 2 months 
of age (48 weeks PMA) with a CVC as evidenced by an adverse event rate less than 10%. 
 
Research Question 2:  
Does twice weekly CHG baths lead to rising (cumulative) CHG blood levels, liver function tests 
(LFTs -AST/ALT) and Serum Creatinine over time in a sample of infants 36 weeks PMA or 
older, and less than 2 months of age (48 weeks PMA) with a CVC? 
 
Hypothesis 2:  
Twice weekly CHG baths do not lead to rising (cumulative) CHG blood levels, LFTs (AST/ALT) 


 
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and Serum Creatinine over time in a sample of infants 36 weeks PMA or older, and less than 2 
months of age (48 weeks PMA) with a CVC. 
 
 
Methods  
 
Study Design: A pilot study using a single arm trial design.  
 
Study Sample: Our convenience sample will include 50 infants. Infants admitted to the NICU or pediatric 
CICU will be eligible to participate.  
 
Inclusion criteria.  
• 
Greater than/equal to 36 weeks PMA (gestational age + chronological age)  
• 
Less than/equal to 48 weeks PMA (gestational age + chronological age) 
• 
Greater than/equal to 3 days of age   
• 
Existing or soon to be placed, peripheral or surgical CVC 
• 
Permission to participate in trial by attending physician  
• 
Parent or legal guardian informed consent to participate in the trial 
 
Exclusion criteria. 
• 
Infant with a large open lesion or severe skin condition (i.e., Myelomeningocele, Gastroschisis, 
lymphatic malformation, open chest, ostomies and/or mucus fistulas or Icthyosis) 
• 
Infants with active seizure disorders  
• 
Infants with Hypoxic Ischemic Encephalopathy  
• 
Infants with severe multi-system organ failure or Liver failure as defined by documentation of 
abnormal liver function tests: alanine aminotransferase (ALT) and aspartate aminotransferase 
(AST) Gamma-glutamyltransferase (GGT) and L-lactate dehydrogenase (LD). 
• 
HCT </= 28%: Respiratory support (mechanical ventilation, continuous positive airway pressure 
or high flow nasal cannula with FiO2 > 25% Oxygen by nasal cannula > 1 liter/min) or  
HCT </= 25%: No respiratory support. 
• 
Infant with renal impairment as defined by: documented serum Creatinine greater than 0.7, renal 
disorders (renal agenesis, polycystic kidney disease, dysplastic kidneys, acute renal injury). 
• 
Infants deemed clinically unstable by their physician such as patients that are extremely fragile 
and wouldn’t tolerate the stimulation of the bathing process or those infants being considered for 
withdrawal of care. 
 
 
Setting: Boston Children’s Hospital (BCH), a non-profit, Magnet® certified pediatric teaching and 
research hospital, is a 395 bed hospital that admits over 17,000 patients per year. This study will be 
conducted in our 24-bed Level IV NICU and a 29 bed pediatric CICU; both serve as tertiary care referral 
centers for critically ill infants.  
 
During 2012, BCH NICU admitted 616 critically ill infants; 463 infants were admitted to the medical 
service and 153 were admitted to the surgical service. (NICU, 2012) The average length of stay was 12.7 
days with a range of 2- 273 days.  The BCH NICU admits infants up to 64 weeks PMA (6 months), 
though more than 98.7% of infants admitted during 2012 were less than 48 weeks PMA (2 months), and 
86.5% were admitted at less than 44 weeks PMA (1 month). The NICU patient population consists of 
infants with complex medical and surgical conditions, with a vast range of diagnoses including, but not 
limited to Prematurity (41.4%), Respiratory distress-multiple causes (17%), rule out seizures (5%) and 
Patent Ductus Arteriosus (2%).  In 2012, the NICU maintained an average of 3187 central lines days 


 
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though this number does not reflect the presence of multiple simultaneous central lines on any given 
patient. 
 
In 2012, BCH pediatric CICU admitted 1364 critically ill children with 377 admissions being less than 2 
months of age (48 weeks PMA; CICU 2012). The average LOS for this age group was between 9-15 
days.   The pediatric CICU maintained 6,917 CVCs, and nearly 100% of infants requiring surgical 
correction for their cardiac anomaly have at least 1 CVC placed. 
 
Study Procedures: 
 
Enrollment. Study nurses will be responsible for screening patients and identifying potential study 
subjects.  Bedside nurses, nurse practitioners or physicians will ask parents of potential study subjects if 
they are interested in hearing about the study.  To obtain consent, the study nurses (trained in obtaining 
consents) will approach parents interested in hearing about the study.  The study nurses will explain the 
study and allow for questions to be answered.  Parents will be given ample opportunity to make their 
decision (few days- depending on the infant’s age and predicted length of treatment with CVC). Parents 
who wish to have their infant participate will be asked to sign informed consent/HIPPA forms. A copy of 
the consent and HIPPA form will be given to the parents and a copy will be placed in their medical 
records.  The original consent and HIPPA forms will be maintained in a locked file cabinet behind a 
locked door in the NICU accessible only to members of the study team.  Once informed consent and 
HIPPA forms are signed, a prescriber will place a standing order to facilitate commencement of bi-weekly 
CHG baths and blood collection procedures. 
 
CHG Bath Cloth Supply, Labeling, Accountability and Storage.  
• 
A supply of 2% CHG impregnated bath cloths will be purchased for this study by the NICU and 
Pediatric CICU and delivered directly to the Investigational Drug Service (IDS) pharmacy.  
• 
The investigational pharmacist will properly label all bath cloths according to 21CFR 312.6 with 
the following statement “Caution:  New drug—limited by federal (or United States) law to 
investigational use”. 
• 
Each label will bear a unique identifying number for the drug product so that it may be tied to 
each patient receiving the study drug. An additional label will be generated at the same time to 
track the product. 
• 
Properly labeled bath cloths with the additional label will be delivered by IDS Pharmacy staff and 
placed directly into the 7 North study cloth warmer behind a locked door. (The cloth warmer will 
be housed in an on-call room adjacent to the NICU that has very limited access. It is behind two 
locked doors that require code and ID card for entry; this location was deemed the “most secure” 
area without being too far from the NICU by members of the study team). 
• 
Properly labeled bath cloths with the additional label will be delivered by ISD Pharmacy staff and 
placed directly into the locked study cloth warmer in the CICU. (The cloth warmer will be housed 
in a locked unit that requires ID card for entry and a locked warmer that requires a code to enter, 
and only study team members will have access to the code). 
• 
To ensure all bath cloths are warmed prior to use, the PI or her designee will document the 
warmer temperature on the CHG Warmer Temperature Log (Appendix A) daily.  One CHG 
Warmer Temperature log will be kept with each warmer in the NICU and the CICU. 
o The warmer temperature of 100°F (37.8oC) is in compliance with the package label and is 
compliant with the FDA’s recommendation. The PI and one alternate (co-investigator) 
will have the passcode key that is required to adjust the set temperature. The Sage 
warmer is also equipped with status indicators for heating each individual package.  A 
red light blinks to indicate when the CHG Cloths are to be disposed (after 84 hours in the 
warmer). 


 
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• 
Nurses performing the CHG bath intervention in the NICU and pediatric CICU will sign and date 
the extra label bearing the unique identifying number and place it on the CHG Bath Data 
Collection Tool (Appendix B). The nurses will also sign and date the label of the product 
package.  
• 
After use, the used/soiled bath cloths will be disposed of in standard waste receptacles, and the 
empty packaging will be placed in a sealed container in a locked cabinet located in the Annex 
before return to IDS pharmacy. 
 
CHG bath training.  Experienced and trained NICU and pediatric CICU RNs who are familiar with the 
ICU equipment will administer the study intervention (CHG baths).  The RNs will receive training to 
administer baths at a maximum of 2 times a week (Monday and Thursday). The RNs will wash around 
any tubes, drains and wires that need to stay in place during the bathing procedure. If needed, wires and 
leads can be changed at this time to allow thorough cleansing of all intact skin surfaces. The bathing 
procedure is as follows:  
• 
Assess whole body for any skin lesions before bathing 
• 
Apply clean diaper to the study subject and fold the diaper down to the abdominal crease in the 
front and the level of the iliac crest in the back 
• 
Perform bath using pre-warmed 2% CHG impregnated rinse-free cloths by Sage Inc. Each 
package is for individual use only  
• 
Cleanse body downward, starting at the neck 
• 
Rub area to be cleansed with a back and forth motion  
• 
Use 1 cloth for neck, arms, and legs (stopping at ankles to prevent wiping of feet/heels)  
• 
Use second cloth for torso and back 
 
 
CHG Bath Intervention. Subjects whose parents consent for this study will receive a CHG bath twice 
weekly. The CHG baths will be performed by 1 of 5 trained study nurses on each unit to ensure a standard 
bathing technique.  Baths will be performed every Monday and Thursday during the day shift, for up to 
12 weeks post enrollment or until the CVC is removed or the patient is discharged.  Nurses will use pre-
warmed 2% CHG impregnated non-sterile cloths from Sage Products Inc.  CHG bath cloths will be pre-
warmed to 100oF (37.8oC) in the warmers provided by Sage Products Inc.  Baths will entail cleaning the 
infants with 2 CHG bathing cloths (1 package) beginning at the neck, working down the body toward the 
feet.  Nurses will be instructed not to use the CHG cloths on the face, scalp, or over open body orifices or 
wounds, including the genitalia and anus (where bloodstream absorption is enhanced).  The genital and 
anal areas will be protected by placing a clean diaper on the study subject prior to initiation of CHG bath. 
Cleansing of the feet/heels with CHG will be avoided due to the possibility of blood sample 
contamination as explained by Cowen et al (1979). Nurses will document completion of the CHG baths 
on the CHG Bath Data Collection Tool that will be kept at each participant’s bedside. When a bath needs 
to be delayed for clinical reasons, it will be done as close to the scheduled time as possible.  
 
Cleansing between CHG baths: Cleansing of infants between CHG baths may be required if they become 
soiled. These baths or partial baths will be done per NICU standard of care using (non-CHG) Comfort 
Cloths by Sage Products Inc. and documented on the CHG Exposure and Comfort Cloth Bath Log 
(Appendix C). 
 
CHG Exposure: Infant participants have the potential for additional CHG exposures for central line 
insertions, dressing changes, and perioperative bathing. Additional CHG exposures will be recorded on 
the CHG Exposure and Comfort Cloth Bath Log.  
 
 


 
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Monitoring for Adverse Events  
 
Full Body Skin Assessment. Study nurses will perform a full body skin assessment for skin irritation or 
open areas on infants prior to each bath.  Following each bath, bedside nurses will conduct a full body 
assessment every 12 hours for the duration for the study (with the last assessment performed 36 hours 
after the last bath or prior to discharge- whichever occurs first).  Full body assessment for altered skin 
integrity will be documented on the CHG Skin Assessment Log (Appendix D) provided for each 
participant. Full body assessment revealing untoward or adverse findings will also be recorded on the 
CHG Adverse Event Reporting Tool- Alteration in Skin Integrity (Appendix E) and reported to the PI.  
 
CHG Measurement. Serum CHG levels will be quantified weekly by a clinical chemistry fellow with 
expertise using High Performance Liquid Chromatography coupled with tandem mass spectrometry (LC-
MC/MS). Briefly, CHG will be extracted from 200uL of serum following deproteinization with 0.1% 
formic acid and addition of a deuterated CHG internal standard.  Reversed phase HPLC separation and 
elution will be performed using a Waters Acquity® UPLC system with a C18 column.  Detection and 
quantification will be achieved on a Waters QuattroTM triple-quadropole mass spectrometer by 
electrospray ionization in positive ion mode (Chapman, et al 2013).  
 
CHG blood levels. CHG blood level assays will be performed to determine CHG levels in study 
participants; but will not be used to inform clinical decision-making since safe blood levels of CHG are 
not known. Thus CHG blood level assays will not be used as the primary method of determining adverse 
reactions.  
 
Instead, we will employ the current standard of care for determining adverse reactions to topically applied 
CHG, which is the visual and clinical assessment of nursing and medical staffs for symptoms of an 
adverse reaction.  In this study, visual and clinical assessments for symptoms of an adverse reaction will 
serve as our primary measure for safety. 
 
We plan to examine associations between CHG blood levels and other adverse reactions (skin irritation or 
open areas, abnormalities in liver and renal function tests) to help determine safe blood levels in infants 
36 weeks PMA or older and less than 48 weeks PMA. Clinical decisions regarding potential reactions will 
be based on the evidence of adverse events from the visual and clinical assessments for symptoms of an 
adverse reaction. 
 
Presently, there are no certified calibrators or standards available for CHG blood levels.  Complete 
validation of the assay for CHG blood levels for use in clinical decision-making would require significant 
regulatory processes.  This would include comparing our assay to those in the literature so that any 
clinical decision points could be established based on the published in vitro and in vivo data. 
 
In this study, analysis of CHG blood levels will be conducted using a liquid chromatography-mass 
spectrometry system in the Department of Lab Medicine, assay development laboratory at Boston 
Children’s Hospital.  The developed assay for CHG blood levels will not be conducted under the CLIA 
accreditation of the laboratory and is for research use only (RUO).  As such, data from this assay cannot 
be used for individual patient decision-making (such as discontinuing CHG exposure).   
  
Assay from our laboratory will allow us to measure CHG at 5 ng/mL or even lower; providing greater 
detail and understanding of the kinetics of absorption and elimination.  This is comparatively better than 
most studies in the literature.  In the majority of published studies, CHG in the blood was not quantifiable 
since the lower limits of quantification, for their instruments, was 20 ng/mL. 
 


 
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If validation were to be conducted using the available instrumentation in the main clinical laboratory, 
which would allow clinical decision making from individual results, the current clinical mass 
spectrometers would perform similar to those in the literature.  They would be unable to detect CHG in 
many samples due to insufficient limits of quantification. This is because these clinical laboratory 
instruments are a generation behind that in the assay development laboratory.  
 
Moreover, utilizing the assay development laboratory will also allow greater flexibility regarding when 
analyses can be conducted for this study. Testing in the assay development laboratory is more flexible 
from timing and cost perspectives, and will be conducted weekly based on sample availability; as opposed 
to the fixed schedule in the main clinical laboratory.  
 
Assessment of Liver and Renal Function. Most drugs or chemicals are excreted from the body via the 
hepatic or renal systems.  Therefore, standard LFTs, namely AST and ALT, and the Serum Creatinine 
levels will be monitored on all subjects. If these labs have been obtained as part of the standard of care, 
the results will be used by the study team and not repeated in order to minimize additional blood loss or 
iatrogenic anemia.  However, if the study subject’s diagnosis did not warrant monitoring of these labs, 
they will be obtained weekly with the CHG blood level.  
 
Procedures for Obtaining CHG, ALT, AST and HCT levels.  A single CHG level will be obtained at 
baseline and then weekly on Fridays for the remainder of the study for each study participant.  Every 
Friday additional labs will be obtained to monitor liver and renal function (AST, ALT, Serum Creatinine) 
and HCT for anemia.  
 
Often these lab values are obtained as part of routine care in the ICU. If these labs have not been obtained, 
they will be added to the weekly labs that will require an additional 1.0 mLs. The study personnel 
performing the bath will assess the need for the additional labs and notify the bedside nurse so that these 
labs can be obtained at the appropriate time as per the CHG Study Research Order (Appendix F).  The 
study labs will be drawn with other lab work via central line whenever possible. If no other lab work is 
scheduled to be obtained, or if the central line gauge is too small (less than 2.6 Fr), then the labs will be 
obtained at the designated time by heel stick. When no other lab work is to be obtained, infants will need 
1-2 heel sticks per week for a required sample of 1- 1.5 mLs in order to limit access of CVC and 
minimize risk of infection.  Standard heel sticks are safely performed on patient care units using the 
lateral aspect of the infants’ pre-warmed heel. Blood levels will be recorded on the CHG Lab Work Log 
(Appendix G) and entered into a computerized database. Lab specimens for this study will be tracked by 
utilizing a CHG Study Lab Requisition Form (Appendix H) that bears the patients study ID number 
followed by a unique specimen identifier (i.e. Patient ID “#CHG001” followed by unique lab identifier 
“3456”).   
 
Assessment for Iatrogenic Anemia.  CHG levels being obtained for this study require 0.5mL for each 
sample. The volume of blood for the ALT/AST/ Serum Creatinine level is 0.5 mL and the hematocrit 
(HCT) is 0.5mls. The minimum total blood volume obtained per week will be 0.5 mL, and the maximum 
total blood volume obtained per week will be 1.5 mLs.  If a study participant were to remain in the study 
for the maximum length of time (12 weeks) the maximum amount of blood obtained for the study will be 
18 mLs (0.5mL at baseline, 1.5 mL weekly for CHG levels, ALT, AST, serum creatinine and HCT). If the 
HCT and Serum Creatinine have already been obtained as part of the infant’s routine ICU bloodwork as is 
often the case (and not for the study), the maximum blood obtained for the study is 12.5 mLs (0.5mL at 
baseline, 1 mL weekly for CHG levels, ALT, AST).  
 
To put this in perspective, the average blood volume for a full term or near term newborn is 80mL/kg 
(160 mL for a 2 Kg infant).  Infants born at 36 weeks gestation, weigh between 2.5-3.5 Kg with an 
average weight of approximately 2.8 Kg, thus their estimated blood volume is 224 mLs. Iatrogenic 


 
9 
Version 16 9.1.16 
anemia occurs when blood loss exceeds 20 % in a 48-hour period (44.8 mL in a 2.8 Kg infant). Thus, it is 
unlikely that an infant would sustain iatrogenic anemia from participating in this study.  However, blood 
volume removed will be maintained on the CHG Lab Work Log for each study subject throughout study 
participation (in order to monitor blood volume removed for study lab work). If the study labs are 
consistently added on to the study subject’s routine lab work, and thought to pose an additional clinical 
risk in terms of blood loss, the DSMC and the FDA will be notified.  
 
Although iatrogenic anemia is unlikely to result from participating in this study our patient population is 
at risk for the development of anemia from a number of potential contributors including: blood loss 
sustained from invasive procedures such as surgery, low iron stores, bone marrow suppression or 
intracranial hemorrhage. This warrants monitoring for anemia during the course of this investigation. For 
the purpose of this study anemia is defined as HCT </= 28% with respiratory support (mechanical 
ventilation, continuous positive airway pressure or high flow nasal cannula with FiO2 > 25% or Oxygen 
by nasal cannula > 1 liter/min) or HCT </= 25%: no respiratory support.  To monitor infants for the 
development of anemia during the study, we will be obtaining weekly HCT levels on infants that do not 
have a weekly HCT levels documented in their medical record. A plan for the management of infants with 
anemia has been put in place and is outlined later in this protocol under Table 1: Management of Adverse 
Events to CHG Baths.    
 
Data Collection. Data collection will be performed by study nurses in the NICU and pediatric CICU.  
Data collection procedures by the study nurses will consist of: 
1. Assigning study ID numbers. 
2. Recording bi-weekly CHG baths on the CHG Bath Data Collection Tool.  
3. Maintaining an on-line password protected database that will be used to record participants CHG 
blood levels, AST, ALT, HCT, serum Creatinine and untoward/adverse skin events and 
CLABSIs.  
4. Recording the incidence and severity of untoward/adverse skin reactions and adverse events 
experienced by study subjects on the CHG Adverse Event Reporting Tool-Alteration in Skin 
Integrity or CHG Adverse Event Reporting Tool-Events Not Related to Skin (Appendix I). 
5. Maintaining a computerized log to track the development of skin reactions, elevated CHG and 
other blood levels, anemia and hours/days of onset of adverse event from time study initiated. 
6. Maintaining a computerized log of all CHG levels (this will be maintained by the study personnel 
in the laboratory). 
 
The study PIs will be responsible for following up on adverse events and contacting the Data and Safety 
Monitoring Committee (DSMC) for consultation. 
 
Phototherapy. To track study participants who are receiving phototherapy we will include a data 
collection point on the CHG Skin Assessment Log.  This data collection point will enable the RN 
completing every 12 hours skin assessments to indicate if the infant is receiving phototherapy.  This will 
allow the investigators to determine if a relationship between CHG level and phototherapy exists.   
 
Study Participation Ends. Infants will remain in the study up to 48 weeks PMA (maximum of 12 weeks), 
upon hospital discharge/transfer, or until the CVC is removed. 
 
Data Management and Quality Control. The Cardiovascular and Critical Care Nursing Research Group 
(CCCNRG) will be responsible for all data management procedures and will provide support to the 
research team during the course of the investigation. The CCCNRG employs experienced research 
personnel.  Also all study staff will be CITI program trained. Study staff will have access to designated 
desk spaces and hospital maintained computer and printing systems.   
 


 
10 
Version 16 9.1.16 
Standard procedures to ensure accurate and reliable collection of data will include well designed forms 
with clear instructions, training of staff, and on-going monitoring of all study activities. A manual of 
operations that describes the purpose of the study, eligibility criteria, and all intervention and assessment 
procedures will be developed by the study investigators. Study staff will be trained by the study 
investigators to conduct informed consent, bathing technique, research assessments, and complete case 
report forms. Furthermore, the primary investigator will provide oversight of all research activities to 
ensure proper data collection procedures and to monitor staff performance.  
 
Subject confidentiality will be maintained using unique study identification codes. The CHG Active Study 
Participant Log (Appendix J) will be used to assign ID numbers and to record the identifiers for contacting 
and tracking subjects. An electronic copy of the log will be kept by the data manager in a file accessible 
only to study staff, in a computer folder with restricted access. Identifiable data, such as patient name, 
contact information and medical record numbers will be recorded and stored separately from the research 
data.   
 
All data will be recorded on hard copy case report forms (CRF) developed by the research team.  A response 
will be required for all items on the CRF’s.  Options for “missing, not applicable or not done” will be coded 
on the CRF’s with a specify option to explain the reason.  All entries on the CRF’s will be printed legibly 
in black ink. Corrections on CRF’s will be made by drawing a single straight line through the incorrect 
entry and recording the correct data above or next to it. All corrections to data on the CRF’s must be initialed 
and dated. Clarifications to data recorded on the CRF’s will be printed above or next to the item, initialed 
and dated.  Completed case report forms will be stored in individual subject folders in a locked file cabinet 
accessible by authorized study staff only.   
Data collected on case report forms will be entered into the Oracle Health Sciences InForm data capture 
and management cloud platform (www.oracle.com). InForm is a comprehensive, integrated, open 
standards-based data capture and management platform that provides: 1) efficient and accurate data 
collection; 2) easy consolidation and transformation of data from multiple sources-EMR; 3) complete 
core data capabilities 4) advanced query management, study design and coding; and 5) full service 
deployment capabilities. InForm is HIPAA-certified and supports 21 CFR Part 11.  The CCCNRG will be 
responsible for double data entry procedures. Double data entry will be conducted on a random sample of 
10% forms to evaluate and correct entry errors. System security is maintained by requiring user 
authentication to gain access to the file on the hospitals private secure network. Only authorized users are 
permitted access to the data files, and daily server back-up activities are executed to ensure data recovery. 
The InForm platform and all electronic files will be saved on the hospital’s limited access servers 
protected by hospital security and back up procedures.  All exported data sets will undergo final data 
cleaning using SAS or similar packages using programmed logical routines unique to each data set. 
Outliers will be resolved prior to any data analysis. In addition, regular study status reports will be 
produced and reviewed by the PI to monitor recruitment, CRF data entry status, missing data frequencies, 
out of range values, adverse events and quality metrics. 
 
Random observations of CHG baths will be performed throughout the entire study period by a designated 
clinician to ensure that all nurses are bathing the infants using the same technique.  Each study team 
member actively bathing study subjects will be audited a minimum of once every two months. These 
observations will be documented on the CHG Bath Audit Tool (Appendix K) and scores of 15/15 points 
are acceptable. Any score lower than 15 will require retraining on the bathing technique.  Also to 
facilitate reliable assessment of skin lesions, a CHG Erythema Assessment Tool (Appendix L) will be 
available for nurses to follow during their assessments (maintained at each study patients’ bedside) 
(Figure 1.). 
 


 
11 
Version 16 9.1.16 
The sponsor-investigator will also engage the services of a qualified independent monitor to ensure the 
protection of the rights of human subjects, the safety of all subjects involved in the investigation and the 
quality and integrity of the data resulting from the trial.  The independent monitor will conduct a pre-
monitoring set-up visit and a monitoring visit after every fifth patient has been recruited and on the study 
for 1 week.   
 
Data Analysis. With the support of a faculty statistician from the BCH Center for Patient Safety and 
Quality Research, we will use descriptive statistics including mean, median, range, and frequencies to 
describe the study sample and the findings (skin findings and adverse events). We will characterize the 
study sample on demographic and clinical characteristics.  Our primary outcome measures will be 
proportion of subjects that experience any adverse event, and the rate of adverse events per 100 patient-
days of follow-up. Our inferential statistics will calculate 95% confidence intervals around these 
estimates.  
 
 
Research Question 1: 
Are twice weekly CHG baths safe for use in a sample of infants 36 weeks PMA or older, and less 
than 2 months of age (48 weeks PMA) with a CVC? 
 
Data Analysis 1:  
Descriptive statistics including mean, median, range and frequencies will be used to describe 
adverse events (including skin reactions and other untoward events). We will characterize the 
demographic and clinical characteristics of subjects that experience adverse events, although we 
will not perform hypothesis tests of association. We will consider time-to-rash data using Kaplan-
Meier estimators. 
 
Research Question 2:  
Does twice weekly CHG baths lead to rising (cumulative) CHG blood levels, liver function tests 
(LFTs -AST/ALT) and Serum Creatinine over time in a sample of infants 36 weeks PMA or 
older, and less than 2 months of age (48 weeks PMA) with a CVC?  
 
Data Analysis 2:  
Descriptive statistics including mean, median, range and frequencies will be used to describe 
CHG, LFTs and serum Creatinine blood levels over time. We will examine scatterplots and other 
graphical analysis of blood level dispersion over time to look for relationships. 
 
 
Sample Size Justification. The primary quantitative goal of this study is estimation of the adverse event 
rate per 100 patient days. The study sample size will impact the precision of this estimate, and we will 
establish an upper bound on the rate if zero adverse events occur. In this context, we designed the study 
sample to expand the existing knowledge base. 
 
 
Based on recent safety data (Quach, et al 2014) on roughly 200 neonates which recorded no adverse 
events, we assume the rate of adverse events using CHG bath is lower than 5 events per 1000 days of 
post-exposure follow-up.  We propose following N=50 subjects over 7 days of post-exposure follow-up, 
for a total of 350 observation days.  Assuming rates of 3.5 events or 1.0 events per 1000 days of follow-
up, the probability that at least one subject will experience an adverse event is roughly 83% or 40% 
respectively. Using Monte Carlo simulations, the mean upper bound for estimable rates is 5.5 events per 
1000 days. 
 
Auditing and Inspecting: 


 
12 
Version 16 9.1.16 
 
The sponsor-investigator will permit study-related monitoring, audits, and inspections by the Boston 
Children's Hospital IRB, the independent data monitor and government regulatory bodies, of all study 
related documents (e.g. source documents, regulatory documents, data collection instruments, study data 
etc.).  The Investigator will ensure the capability for inspections of applicable study-related facilities. 
 
 
Human Subjects:  
 
BCH Committee for Clinical Investigation approval will be obtained before study procedures commence. 
All study staff will be Citi-program trained. Informed consent/HIPPA forms will be secured before 
initiation of any study procedures. A computerized database to track subjects through the research 
continuum will be developed and housed on a password-protected site behind the BCH firewall. Subjects 
will be assigned study ID numbers that will appear on all study materials and that will be utilized in place 
of subjects’ names in the computerized database. A separate (electronic) CHG Study ID Assignment Log 
linking subject’s names and ID numbers will be maintained by study personnel and kept in a locked 
cabinet behind a locked door. Only approved study personnel will have access to the log. 
 
This study is considered greater than minimal risk with a potential for direct benefit.  There is strong 
evidence that CHG will help prevent HAIs, however the safety profile for using CHG in infants less than 
2 months of age (48 weeks PMA) is not known.  To monitor for adverse events, the study team has 
developed a Data Safety Monitoring Plan (DSMP) and adverse event management plan (see Table 1).  
Adverse events to CHG baths include mild to severe skin lesions and possible absorption of CHG into the 
blood that could result in more serious problems such as respiratory, renal and liver problems or 
anaphylaxis.  Thus the study team is taking a conservative approach.  In an attempt to usurp the benefits 
associated with CHG while concurrently minimizing the likelihood of adverse events, study subjects will 
receive twice-weekly, instead of daily, CHG baths.   
 
While these baths still place the subjects at risk for adverse events we believe twice-weekly baths will 
minimize these risks.  To monitor for adverse events the study team has developed the following 
procedures: 
1. Study RNs will perform a full body skin assessment for skin irritation or open areas prior to each 
bath.  
2. Bedside RNs will complete skin assessments every 12 hours during the course of the study. 
3. A plan is in place for Management of Adverse Events to the CHG Baths. (Table 1.)  
4. To monitor for absorption into the blood, infants will have blood levels (CHG, ALT, AST, and 
Serum Creatinine) drawn at baseline and weekly and when an infant is removed from the study in 
response to an adverse event.  In addition, infants will be monitored weekly for the development 
of iatrogenic anemia.  
 
Data Safety Monitoring Plan:  
 
The DSMC will review all adverse events experienced by the study subjects.  All CHG levels obtained 
(up until the week prior to the meeting) will be available for review by the DSMC. The DSMC will 
consist of 5 expert clinicians throughout the institution including: a Clinical Nurse Specialist (skin care 
specialist), attending medical physician from the NICU or CICU, a Doctor of Pharmacy, an Infection 
Control expert and a Laboratory Medicine physician.  They will assist the study team in making informed 
decisions about the management of adverse events, including study closure if warranted. At minimum, the 
PIs will contact members of the DSMC via email with a summary of the study findings, including 
available CHG levels, LFTs (AST/ALT), Serum Creatinine and HCT levels, at the following intervals 
during the course of the study: 


 
13 
Version 16 9.1.16 
• 
After the first 10 subjects have enrolled and participated in the study for a minimum of 2 
weeks.  During this meeting the DSMC will discuss the need to revise the plan 
(frequency) for obtaining LFTs, Serum Creatinine and HCT 
• 
Following completion of the study by 25 subjects  
• 
At the conclusion of the study  
More frequent meetings may be required if serious adverse events are noted (Table 1, #5-8).  
 
Adverse Event Management: 
 
Criteria for Holding or Stopping the Study 
Table 1 delineates criteria for holding and stopping rules for study subjects based on skin and lab and 
clinical assessments. Holding rules apply to study subjects that will no longer receive CHG baths, such as 
following the need for a blood transfusion, adverse event, or infants that become clinically unstable. 
Infants whose participation is placed on hold will have monitoring of daily vital signs (ranges), HCTs (if 
anemia was the cause of the hold), and documentation of significant clinical changes. This information 
will be recorded on the CHG Vital Sign and Clinical Monitoring Tool (Appendix M). Stopping rules 
apply to study participants that have had CHG baths placed on hold and have completed necessary 
monitoring described in holding rules.  Furthermore, all adverse events will be recorded on the 
Adverse Event Reporting Tools. 
 
Holding and Stopping Rules 
 
Anemia/Blood Transfusions: 
Holding rules for patients with anemia requiring blood transfusion. All study participants that require a 
blood transfusion while enrolled in the study will have CHG baths suspended until 1-week post 
transfusion and will have a pre- and post-transfusion assessment of vital signs (ranges-heart rate, 
respiratory rate, blood pressure, oxygenation requirement and means of respiratory support).  A post-
transfusion hematocrit will also be obtained, if not attained via standard of care, and documented on the 
CHG Blood Transfusion Tool (Appendix N).  The CHG baths will resume 1-week post transfusion if 
study participant is deemed stable by both the study and medical teams.  
 
Study participants that do not receive a blood transfusion or are deemed not stable will have monitoring 
of daily vital signs (ranges-heart rate, respiratory rate, blood pressure, oxygenation requirement and 
means of respiratory support), HCTs that are obtained as routine ICU care, and significant changes to 
clinical status for 1 month from cessation of CHG baths or until discharge, whichever comes first to 
assess for adverse events related to anemia.   
 
Stopping rules for patients with anemia requiring blood transfusion. All study participants that have had 
CHG baths suspended and that do not receive a blood transfusion or are deemed unstable will be removed 
from the study after completing the clinical monitoring as described above. 
 
Adverse Event (Other Than Anemia):  
Holding rules for patients that experience an adverse event: All study participants that experience an 
adverse event, as described in table 1, and have CHG baths suspended due to the adverse event will have 
2 CHG levels obtained within 1 week of CHG bath (recorded on CHG Lab Work Log), unless the 
previous level was not detectable.  These infants will also have monitoring for adverse event symptom 
resolution and daily vital signs (ranges-heart rate, respiratory rate, blood pressure, oxygenation 
requirement and means of respiratory support) for 1 month from cessation of CHG baths or until 
discharge, whichever comes first.  
 


 
14 
Version 16 9.1.16 
Stopping rules for patients that experience an adverse event. All study participants that have CHG 
baths suspended due to an adverse event will be removed from the study after completing the 
clinical monitoring as described above. 
 
 
 
Clinical Instability: 
Holding rules for patients that become clinically unstable. For the safety of the study participant bathing 
will be suspended for infants demonstrating significant or acute impairment of their clinical status as 
indicated by their medical team.  For example, patients requiring volume resuscitation due to blood and 
fluid losses, or a patient in the immediate post-operative period will not be bathed until return to baseline 
stability. These patients will have 2 CHG levels obtained within 1 week of last CHG bath, unless previous 
level was non-detectable. Infants deemed not appropriate for participation by either the study team or 
medical team will have monitoring of daily vital signs (ranges-heart rate, respiratory rate, blood pressure, 
oxygenation requirement and means of respiratory support) for 1 month from cessation of CHG baths or 
until discharge, whichever comes first.  
 
Stopping rules for subjects that become clinically unstable. Study subjects whose clinical status does 
not return to baseline, as assessed by both the study and medical teams will be removed from the 
study after completing the clinical monitoring for 1 month as described above. 
 
 
Table 1: Management of Adverse Events to CHG Baths   
 
Erythema Assessment  (see CHG Erythema Assessment Tool for visual comparisons) 
 Finding 
Action 
Follow Holding and 
Stopping Rules 
Reporting 
 
 
1. Mild redness X1 
None 
Not Applicable 
 
No immediate action; Send 
email update to PI; include 
in monthly DSMP report 
 
2. Mild redness X2, 
persistent redness 
leading up to 2nd bath, or 
moderate redness: 
Discontinue 
CHG baths 
(unless rash is 
limited only to 
diaper area) 
 
Adverse Event (Other 
Than Anemia) 
 
Immediately reportable to 
PI; include in monthly 
DSMP report 
3. Raised rash 
Discontinue 
CHG baths 
(unless rash is 
limited only to 
diaper area) 
 
Adverse Event (Other 
Than Anemia) 
 
Immediately reportable to 
PI; include in monthly 
DSMP report 
4. Blister(s) 
Discontinue 
 CHG baths 
Adverse Event (Other 
Than Anemia) 
Immediately reportable to 
PI; meet with DSMC 
 
5. Open area(s) 
Discontinue 
CHG baths 
Adverse Event (Other 
Than Anemia) 
Immediately reportable to 
PI; meet with DSMC 
 


 
15 
Version 16 9.1.16 
6. Evidence of systemic 
event  
Discontinue 
CHG baths  
Adverse Event (Other 
Than Anemia) 
Immediately reportable to 
PI; meet with DSMC 
 
7. Anaphylaxis 
Discontinue 
CHG baths 
Adverse Event (Other 
Than Anemia) 
Immediately reportable to 
PI; meet with DSMC 
 
Lab Value Assessment  
AST >70 u/l 
Discontinue 
CHG baths 
Adverse Event (Other 
Than Anemia) 
Immediately reportable to 
PI; meet with DSMC 
 
ALT >60 u/l 
Discontinue 
CHG baths 
Adverse Event (Other 
Than Anemia) 
Immediately reportable to 
PI; meet with DSMC 
 
Serum Creatinine 0.7 
mg/dl or greater 
Discontinue 
CHG baths 
Adverse Event (Other 
Than Anemia) 
Immediately reportable to 
PI; meet with DSMC 
 
HCT </= 28%: 
Respiratory support 
(mechanical ventilation, 
continuous positive 
airway pressure or high 
flow nasal cannula with 
FiO2 > 25%   
Oxygen by nasal cannula 
> 1 liter/min)  
HCT </= 25%: 
No respiratory support  
 
Discontinue 
CHG baths  
Anemia/Blood 
Transfusions 
Immediately reportable to 
PI; Discuss with medical 
team; meet with DSMC 
 
Other 
Clinical Instability 
Discontinue 
CHG baths 
Clinical Instability 
Immediately reportable to 
PI; include in monthly 
DSMP report 
 
 
 
 
 
Financial Support:  
 
This study is being funded by the Program for Patient Safety and Quality, the Department of Lab 
Medicine Clinical Chemistry Training Program, and the American Association of Critical Care Nurses. 
The nursing departments from the participating units will purchase the 2% CHG cloths for this study. The 
Department of Newborn Medicine will fund all supplemental laboratory specimens.  
 
References: 
1. Mimoz O, Villeminey S, Ragot S, et al. Chlorhexidine-Based Antiseptic Solutions vs Alcohol-
Based Povidone-Iodine for Central Venous Catheter Care. Arch Intern Med 2007;167(19):2066-
72. 
2. Vernon M, Hayden M, Trick WE, et al. Chlorhexidine Gluconate to Cleanse Patients in a Medical 
Intensive Care Unit. Arch Intern Med 2006;166(3):306-12. 


 
16 
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3. Bleasdale S, Trick W, Gonzalez IM, et al. Effectiveness of Chlorhexidine Bathing to Reduce 
Catheter-Associated Bloodstream Infections in Medical Intensive Care Unit Patients. Arch Intern 
Med 2007;167(19):2073-9. 
4. Milstone A, Elward A, Song X, et al. Daily Chlorhexidine Bathing to Reduce Bacteraemia in 
Critically Ill Children: a Multicenter, Cluster-randomized Cross Trial. Lancet 2013;381(9872): 
1099-1106. 
5. Lee A, Harlan R, Breaud AR, et al. Blood Concentrations of Chlorhexidine on Hospitalized 
Children Undergoing Daily Chlorhexidine Bathing. Infect Control Hosp Epidemiol 2011;32(4): 
395-7. 
6. Harpin V, Rutter N. Percutaneous Alcohol Absorption and Skin Necrosis in a Preterm Infant. 
Arch Dis Child 1982; 57(6):477-9. 
7. Powell H, Swarner O, et al. Hexachlorophene Myelinopathy in Preterm Infants. J Pediatr 1973; 
82(6):976-81. 
8. U.S Food and Drug Administartion; Medwatch (internet). Silver Spring, MD, USA. 
(http://www.fda.gov/safety/medwatch/safetyinformation/safetyrelateddruglabelingchanges  
/ucm307387.htm). US Food and Drug Administration; 2012. (Updated 12 June 2012). 
9. O’Grady N, Alexander M, Burns LA, et al. Guidelines for the Prevention of Intravascular 
Catheter-Related Infections. Am J Infect Control 2011;39(4 Suppl 1):S1-34. 
10. Cowen J, Ellis SH, McAinsh J. Absorption of Chlorhexidine from the Intact Skin of Newborn 
Infants. Arch Dis Child 1979;54(5);379-83. 
11. Aggert PJ, Cooper LV, Ellis SH, et al. Percutaneous Absorption of Chlorhexidine in Neonatal 
Cord Care. Arch Dis Child 1981;56(11):878-80. 
12. Tamma PD, Aucott SW, Milstone AM. Chlorhexidine Use in the Neonatal Intensive Care Unit: 
Results from a National Survey. Infect Control Hosp Epidemiol 2010;31(8):846-9. 
13. Popovich KJ, Lyles R, Hayes R, et al. Relationship Between Chlorhexidine Gluconate Skin 
Concentration and Microbial Density on the skin of Critically Ill Patients Bathed Daily with 
Chlorhexidine Gluconate. Infect Control Hosp. Epidemiol 2012;33(9):889-96. 
14. Khoo A, Oziemski P. Chlorhexidine Impregnated Central Venous Catheter Inducing an 
Anaphylactic Shock in the Intensive Care Unit. Heart Lung Circ 2011;20(10):669-70 
15. Kutzscher L, Management of Irritant Contact Dermatitis and Peripherally Inserted Central 
Catheters. Clin J Oncol Nurs 2012;16(2);E48-E55. 
16. Khan RA, Kazi T, O’Donohoe B. Near Fatal Intra-operative Anaphylaxis to Chlorhexidine-Is it 
Time to Change Practice? BMJ Case Rep 2011;10:1136. 
17. Darnstadt GL, Hossain MM, Choi Y, et al. Safety and Effect of Chlorhexidine Skin Cleansing on 
Skin Flora of Neonates in Bangladesh. Pediatr Infect Dis J 2007;26(6):492-5. 
18. Sankar MJ, Paul VK, Kapil A, et al. Does Skin Cleansing with Chlorhexidine Affect Skin 
Condition, Temperature and Colonization in Hospitalized Preterm Low Birth Weight Infants? A 
Randomized Clinical Trial. J Perinatol 2009;29(12):795-801. 
19. Neonatal Intensive Care Unit, Boston Children’s Hospital Annual Report. General Overview. 
2012: 4. 
20. Pediatric Cardiac Intensive Care Unit, Boston Children’s Hospital Annual Report. General 
Overview. 2012 
21. Chapman AK, Aucott SW, Gilmore MM, et al. Absorption and Tolerability of Aqueous 
Chlorhexidine Gluconate Used for Skin Antisepsis Prior to Catheter Insertion in Preterm 
Neonates. J Perinatol 2013;33(10):768-71. 
22. Oracle Health Sciences InForm data capture and management cloud platform (www.oracle.com) 
23. Quach C, Milstone A, Perpete C, et al. Chlorhexidine Bathing in a Tertiary Care Neonatal 
Intensive Care Unit: Impact on Central Line-Associated Bloodstream Infections. Infect Control 
Epidemiol 2014;35(2):158-163. 
24. Kirpalani H, Whyte R, et al. The Premature Infants In Need of Transfusion (PINT) Study: A   
Randomized, Controlled Trial of a Restrictive (Low) Versus Liberal (High) Transfusion 


 
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Threshold For Extremely Low Birth Weight Infants.  J of Pediatrics. Sep 2006; 301-307. 
25. Sola-Visner M, Deschmann E, et al. Evidence Based Guideline for Red Blood Cell Transfusion in 
Neonates <32 Weeks Gestational Age or with Birth Weight <1500 Grams (NICU). Patient Care 
Manual Boston Children’s Hospital, 2015; 1-7. 

ICF_001.pdf: 
DO NOT PLACE IN
MEDICAL RECORD
Pilot Study: Safety of Chlorhexidine (CHG) 
Baths in Patients Less Than 2 Months of Age
Principal Investigator: Celeste Chandonnet
RESEARCH CONSENT FORM
MRN#:
DOB:
Subject’s Name: 
Study ID#:
                         Page 1 of 9                           Version 12 3.7.16        
Why is this research study being conducted? What is its purpose?
The purpose of this research study is to evaluate the safety of twice weekly Chlorhexidine gluconate (CHG) 
baths in hospitalized infants less than 2 months of age (equal to 48 weeks’ postmenstrual age) with central 
venous catheters (CVC) in place.  
The current standard of care at Boston Children’s Hospital (BCH) for infants greater than 36 weeks 
postmenstrual age and less than 2 months of age is twice weekly baths with comfort clothes (Fragrance free, 
hygienic bath cloths with purified water, Vitamin E and Aloe), manufactured by Sage Products Inc. 
Having a CVC places hospitalized infants at increased risk for infection.  These infections can be severe, and 
can make an infant very ill.   
Topically applied CHG antiseptic has been shown to reduce bacteria that can potentially cause skin 
infections in hospitalized adults and older children, but safety concerns have resulted in the limited use of 
CHG on infants less than 2 months of age.   At present time, CHG is only applied to the skin of infants less 
than 2 months of age when CVCs are inserted, during CVC dressing changes and prior to cardiac surgery. 
CHG is not routinely used to reduce skin bacteria during infant baths.
This study involves the use of a CHG soaked antiseptic bathing cloths. The Food and Drug Administration 
(FDA) approves CHG for use with caution in premature infants and infants less than 2 months of age.  This 
is because CHG has been associated with a number of problems including mild skin irritation, allergic 
contact dermatitis (skin rash) and more serious life threatening conditions. However the more serious side 
effects were seen when there has been simultaneous exposure to multiple products containing CHG, or with 
direct contact between the CHG product and the mucous membranes. 
Who is conducting this research study, and where is it being conducted?
This study is being conducted in the Neonatal Intensive Care Unit (NICU) and the pediatric Cardiac 
Intensive Care Unit (CICU) at Boston Children’s Hospital. The primary investigators are Celeste 
Chandonnet BSN, RN, CCRN, CIC and Cheryl Toole MS, RN, CCRN, NEA-BC in collaboration with 
medical doctors, doctors of laboratory medicine and nurses from both the NICU and pediatric CICU. 
Protocol ID:IRB-P00011128                 Activation Date:  January  30, 2017                 Do Not Use After:  January  08, 2018


RESEARCH CONSENT FORM
MRN: _________________________
Pt Name: ______________________
                                                         Page 2 of 9                                       Version 13 8.10.16
How long will my infant be a study participant?
Our goal is to enroll 50 infants total from the NICU and pediatric CICU.  Infants will remain in the study up 
to a maximum 12 weeks’ time, until hospital discharge/transfer, or at the time the CVC is removed. 
(Example: infant enrolled in the study at 36 weeks postmenstrual age has their CVC removed at 42 weeks 
postmenstrual age, will have remained in the study for 6 weeks).
How are individuals selected for this research study? How many will participate?
Your infant has been chosen to participate in the study because he/she is:
A patient in the NICU or pediatric CICU
Greater than or equal to 36 weeks postmenstrual age (gestational age + age in days) 
Less than or equal to 2 months of age (48 weeks postmenstrual age)
Has an existing or soon to be placed, peripheral or surgical CVC
What do I have to do if I am in this research study?
Participation in this study is voluntary.  If you decide to have your infant participate in this study, your infant 
will receive a bath every Monday and Thursday and a blood draw for a CHG level (and possibly additional 
blood work) every Friday.
 
The bath: Study nurses will use pre-warmed 2% CHG soaked cloths from Sage Products Inc. Baths will 
involve cleaning your infant beginning at the neck, working down the body toward the feet.  The study 
nurses will not clean your infant’s face, scalp, feet, body openings and wounds with the CHG cloths.
Skin evaluation: Study nurses will perform a full body skin assessment for skin irritation, or open areas on 
your infant prior to receiving each bath.  Following each bath, bedside nurses will conduct a full body 
assessment every 12 hours for the duration for the study. Any findings that are unfavorable (such as a rash) 
will be documented and reported to the primary investigator.
The blood sample: CHG levels will be obtained before the first bath and on Fridays. Also every Friday 
additional labs may be obtained to monitor your infant’s liver function, renal function and red blood cell 
count, if these labs are not part of your infant’s routine lab work.  All blood levels will be drawn with other 
scheduled lab work using your infant’s CVC whenever possible. When no other lab work is to be obtained or 
if your infant’s CVC is too small to draw blood, your infant will need 1-2 extra heel sticks per week. Heel 
sticks are safely performed on patient care units using the side of your infants’ pre-warmed heel. Heel sticks 
may also be performed to limit accessing your infant’s CVC, minimizing the risk of infection, in some 
situations. 
The maximum volume of blood for these lab tests equals approximately 1/3 of a teaspoon per week.  If your 
infant’s participation in the study is for the maximum length of time of 12 weeks, the total amount of blood 
that will be obtained for this study is approximately 31/2 teaspoons.  
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MRN: _________________________
Pt Name: ______________________
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What are the risks of this research study? What could go wrong?
Participation in this study involves some risk to your infant. While chlorhexidine has become a widely used 
antiseptic, it is not used without risk. Side effects associated with CHG have included mild to severe skin 
reactions and possible absorption of CHG into the blood that could result in changes to liver and renal 
function, reduced red blood cell count and more serious problems such as respiratory problems or 
anaphylaxis (a generalized allergic reaction).  However the most common documented side effect with the 
2% CHG baths cloths has been mild, local skin redness with no serious problems reported. If a severe skin 
reaction does occur such as blisters or burns, we will discontinue the CHG baths and treatment will be 
provided from your infant’s medical provider. Due to the limited use of CHG bathing cloths in infants less 
than 2 months of age there may be risks, which are currently unforeseeable. 
  
Another cause of discomfort to your infant may occur when the CHG level and other blood work is obtained, 
and needs to be drawn by heel stick. Risks associated with a blood draw from a heel stick are minor 
discomfort and bruising. Heel sticks are safely and routinely performed using the side of your infants’ pre-
warmed heel.  A single stick is usually enough for the small sample of blood needed, however more than one 
heel stick may be needed if your infant’s blood clots quickly, preventing collection of the sample. 
Our study team has elected to investigate the safety of twice-weekly 2% CHG baths.  There is some evidence 
to indicate that twice weekly baths may prevent infection; however that has not been proven in patients less 
than 2 months of age.  Since the safety profile for using CHG in infants less than 2 months of age is not known this 
study is considered greater than minimal risk with a potential for direct benefit to your infant.  
To maintain your infant’s privacy and anonymity all records associated with your infant's participation in 
this study will be confidential. However, because the use of this product is regulated by the Food and Drug 
Administration (FDA), the FDA may have access to these records during the course of their duties.
What are the benefits of this research study?
Research in other patient populations supports the use of CHG, a topical antiseptic for reducing healthcare-
associated infections (HAIs) in adult and pediatric patients. It is proven to decrease bacteria on the skin, 
which may help to decrease infections in these patients. Preventing an infection could shorten the length of 
time your infant is hospitalized and could shorten the length of stay for future patients in the NICU and 
pediatric CICU. 
This study will help to establish the safety of twice weekly CHG baths and help determine the need for a 
larger study that will examine infection control.
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MRN: _________________________
Pt Name: ______________________
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Are there costs associated with this research study? Will I receive any payments?
There is no cost for participating in this study.  However, you and your insurance company will be charged 
for routine medical and or nursing care that is considered standard treatment for your infant’s medical 
condition. In addition, neither you nor your infant will be paid to participate in the study. 
In the event of an injury resulting directly from your participation in this research study, medical treatment 
will be provided if the injury is reported in a timely manner.  Provision of such medical care does not imply 
any negligence or other wrongdoing on the part of the Hospital or any of the physicians or other personnel 
involved in the study.  Where applicable, the Hospital reserves the right to seek payment from third-party 
payers for any medical care or services rendered.  The Hospital has no program to provide you with any 
additional compensation as a result of any such injuries.
What will happen with the information obtained as part of this research study? What 
about confidentiality?  
The researchers will make every effort to protect your infant’s identity. To protect your infant, a study ID 
number will be assigned to him/her upon enrollment in the study. This study ID will be used on all study 
documentation including the data collection tool and the special laboratory request form.  All data will be 
entered into a computerized password protected logbook.  The data collection tool will be stored by study 
staff in the primary investigators work room in a locked cabinet behind a locked door and special laboratory 
request forms will be stored by study staff in the laboratory in a locked file behind a locked door and entered 
into the computerized password protected logbook. 
Only the members of the researcher team will have access to the information from this study. However 
Federal and state agencies (for example the Department of Health and Human Services, the Food and Drug 
Administration, the National Institutes of Health, the Office of Human Research Protections, the Department 
of Social Services or other governmental offices as required by law) have authority over the research and can 
request to see your infant’s research records.
Clinical staff not involved in the study, but who are caring for your infant will have knowledge of your 
infant’s participation, but will not have access to your infant’s research records or lab results. The research 
records and CHG lab results will not appear in your infant’s medical record.
 
A copy of this consent form will be placed in your infant’s medical record. Medical records are considered 
permanent records; therefore, materials cannot be deleted from the record. Medical records are available to 
health care professionals at Children's Hospital and may be reviewed by Hospital staff in their course of 
carrying out their responsibilities; however, they are required to maintain confidentiality in accordance with 
applicable laws and Hospital policies. Information contained in you/your infant's medical record may not be 
given to anyone unaffiliated with Children's Hospital in a way that could identify you/your infant without 
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MRN: _________________________
Pt Name: ______________________
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written consent, except as required or permitted by law. Information collected during the study that does not 
become part of your infant’s medical record will be stored in separate research files maintained by the 
investigator. These research records will not be made available to any individuals who are not part of the 
research team unless you so request or as required by law. If you withdraw your infant from the research 
study, information that has already been collected will become part of the research data; however, you/your 
infant will not be identified. 
The results of the study intervention will not be placed in your infant’s medical record. In this manner it will 
be unlikely that others within the hospital, an insurance company or employer would ever learn of such 
results.
  
If I do not want to take part in this research study, what are the other choices?
Participation in this study is voluntary. The treatment being offered is experimental, and there are no 
alternative topical antiseptic treatments being offered. If you choose not to participate in this study or if you 
decide to withdraw your infant from the study, your decision will not interfere with current or future care 
received at Boston Children's Hospital. The current standard of care for infants at BCH is to provide routine 
bathing with Comfort Cloth by Sage Products Inc. CHG is only applied to the skin of infants less than 2 
months of age when CVCs are inserted, during CVC dressing changes and prior to cardiac surgery. 
Currently, CHG is not routinely used to reduce skin bacteria during routine infant baths.
What are my rights as a research participant?
This study is voluntary. If you choose to participate, you have the right to withdraw from the study at any 
time. If you decide not to participate in the study or decide to leave the study early, your decision will not 
affect your relationship with your doctor, nurses or with the hospital. There will be no unfavorable 
consequences for withdrawing your infant from this study. If you decide to withdraw your infant from this 
study, you can do so at any time by notifying your infant’s nurse.  Your infant’s nurse can notify the primary 
investigators. 
In the event of injury (such as blisters or burns, or evidence of renal/liver problems), we will discontinue the 
CHG baths and treatment will be provided from your infant’s medical provider. Due to the limited use of 
CHG bathing cloths in infants less than 2 months of age there may be risks, which are currently 
unforeseeable. 
Why would I be taken off the study early?
Sometimes there are circumstances under which the investigator, without regard to your consent, will stop 
the participant’s involvement. In this study your infant’s participation may be terminated by the investigator 
without regard to the participant's consent if after receiving a CHG bath, the participant experiences:
Mild redness after 2 consecutive baths  
Persistent redness leading up to 2nd bath
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Pt Name: ______________________
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Moderate redness
Raised rash
Blister(s) 
Open area(s) that develop after bath
Evidence of a serious reaction. Examples of serious reactions include inflammation, elevated 
temperature, seizures, and total body rash.
A rapidly progressing, life-threatening allergic reaction such as wheezing, nausea and vomiting, hives 
and altered heart rhythms.
OR:
Due to the following lab results, as it would be dangerous for your infant to continue in the study:
o
Elevated Liver function test 
o
Elevated Kidney function test  
o
Decreased red blood cell count
The Principal Investigator feels it is in the best interest of your infant to be taken off this study.
What information do I need to know about the Health Insurance Portability and 
Accountability Act (HIPAA)?
You/your infant’s health information is protected by a law called the Health Information Portability and 
Accountability act (HIPAA). In general, anyone who is involved in this research including those funding and 
regulating the study may see the data, including information about you.  For example, the following people 
might see information about you:
Research staff at Boston Children’s Hospital involved in this study.
Medical staff at Boston Children’s Hospital directly involved in your care that is related to the research 
or arises from it.
Other researchers and centers that are a part of this study, including people who oversee research at 
that hospital.
People at Boston Children’s Hospital who oversee, advise and evaluate research and care. This 
includes the ethics board and quality improvement program.
People from agencies and organizations that provide accreditation and oversight of research.
People that oversee the study information such as data safety monitoring boards, clinical research 
organizations, data coordinating centers, and others. 
Sponsors or others who fund the research, including the government or private sponsors.
Companies that manufacture drugs or devices used in this research.
Federal and state agencies that oversee or review research information, such as the Food and Drug 
Administration, the Department of Health and Human Services, the National Institutes of Health, and 
public health and safety authorities.
People or groups that are hired to provide services related to this research or research at Boston 
Children’s Hospital, including services providers, such as laboratories, and others.
Your health insurer for portions of the research and related care that are considered billable.
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Pt Name: ______________________
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If some law or court requires us to share the information, we would have to follow that law or final ruling.
Some people or groups who get your infant’s health information might not have to follow the same privacy 
rules. Once your infant’s information is shared outside of Boston Children’s Hospital, we cannot promise 
that it will remain private. If you decide to share private information with anyone not involved in the study, 
the federal law designed to protect privacy may no longer apply to this information. Other laws may or may 
not protect sharing of private health information. If you have a question about this you may contact the 
Boston Children’s Hospital Privacy Office at 857-218-4680, which is set up to help you understand privacy 
and confidentiality.
Because research is ongoing we cannot give you an exact time when we will destroy this information.  
Researchers continue to use data for many years so it is not possible to know when they will be done.
We will also create a code for the research information we collect about your infant so identifying 
information will not remain with the data and will be kept separately. The results of this research may be 
published in a medical book or journal or be used for teaching purposes. However your infant’s name or 
identifying information will not be used without your specific permission. 
Your privacy rights
If you do not want your infant to participate in this study, you do not have to.  If you do want to participate, 
however, you must sign this form.  
If you do not sign this form, it will not affect your care or your infant’s care at Boston Children’s Hospital 
now or in the future and there will be no penalty or loss of benefits.  You can withdraw your infant from the 
study and end your permission for Boston Children’s Hospital to use or share the protected information that 
was collected as part of the research; however you cannot get back information that was already shared with 
others. Once you remove your permission, no more private health information will be collected. If you wish 
to withdraw your infant’s health information, you will need to do so in writing.  
Your infant may have the right to get some the information that was shared with others for research, 
treatment or payment.  This information is available after the study analysis is done.  To request the 
information, please contact the Hospital’s Privacy Officer at 857-218-4680.
Other information that may help you
Boston Children’s Hospital has recently developed a web-based, interactive educational program for parents 
called “A Parent’s Guide to Medical Research.”  To find out more about research at Children’s Hospital, 
please visit the program at www.researchchildren.org. 
Boston Children’s Hospital is interested in hearing your comments, answering your questions and 
responding to any concerns regarding clinical research at Children's Hospital. If you would like further 
information about the type of clinical research performed at the hospital or have suggestions, questions or 
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Pt Name: ______________________
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concerns regarding clinical research you may send an email to cci@childrens.harvard.edu or call 617 355-
7052 between the hours of 8:30and 5:00.
A description of this clinical trial will be available on HTTP://www.ClinicalTrials.gov, as required by U.S. 
Law.  This website will not include information that can identify you.  At most, the website will include a 
summary of the results.  You can search this website at any time. Contact Information
I understand that I may use the following contact information to reach the appropriate person/office to 
address any questions or concerns I may have about this study.  
  I can call…
 At
 If I have questions or concerns about
Study Contacts
Primary 
Investigator:
Celeste Chandonnet
Cell Phone: (603)320-9218 (first call)
Beeper: #4508
In hospital: (617) 355-1920 
Email: Celeste.chandonnet@childrens.harvard.edu 
  General questions about the study
  Research-related injuries or emergencies
  Any research-related concerns or complaints
Co-Investigator:
Cheryl Toole
  Cell Phone: (617)33-7765 
In hospital: (617) 355-7555
  Email: Cheryl.Toole@childrens.harvard.edu
  General questions about the study
  Research-related injuries or emergencies
  Any research-related concerns or complaints
CICU Study Team:
Deb Morrow
  Cell Phone: 
In hospital: 617-355-9859
  Email: Debra.Morrow@cardio.chboston.org
  General questions about the study
  Research-related injuries or emergencies
  Any research-related concerns or complaints
Office of
Clinical 
Investigations
Phone: 617-355-7052
 Rights of a research subject
 Use of protected health information.
 Compensation in event of research-related 
injury
 Any research-related concerns or complaints.
 If investigator/study contact cannot be 
reached.
 If I want to speak with someone other than the  
Investigator, Study Contact or research staff.
Documentation of Informed Consent and Authorization
I have read this consent form and was given enough time to consider the decision to participate in this study.
This research study has been satisfactorily explained to me, including possible risks and benefits.
All my questions were satisfactorily answered. 
I understand that participation in this research study is voluntary and that I can withdraw at any time.
I am signing this consent form prior to participation in any research activities.
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MRN: _________________________
Pt Name: ______________________
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I give permission for my/my child’s participation in this research study and for the use of associated protected 
health information as described above (HIPAA). 
Parent/Legal Guardian Permission (if applicable) 
If the child to be involved in this research study is a foster child or a ward of the state please notify the researcher or 
their staff who is obtaining your consent.
 __________________
____________________________________________
_________________ 
  Date (MM/DD/YEAR)
       Signature of Parent or Guardian
 Relationship to child
Investigator or Associate’s Statement & Signature
I have fully explained the research study described above, including the possible risks and benefits, to all 
involved parties (subject/parents/legal guardian as applicable). 
I have answered and will answer all questions to the best of my ability. 
I will inform all involved parties of any changes (if applicable) to the research procedures or the risks and benefits 
during or after the course of the study. 
I have provided  a copy of the consent form sign by the subject/ parent / guardian and a copy of the hospital’s 
privacy notification  (if requested)
__________________
____________________________________________
   
Date (MM/DD/YEAR)
Signature of Investigator or Associate
Witness Statement & Signature
Required ONLY IF (check which one applies):
Consent document needs to be read to subject or legal representative, or 
Communication impairments limit the subject’s ability to clearly express consent, or 
Other reason: please specify _____________________________________________
I confirm that the information in this consent form was accurately explained to, and understood by the subject, parent 
and/or legally authorized representative as required, and that informed consent was given freely.
__________________
____________________________________________
   
Date (MM/DD/YEAR)
Signature of Witness
Protocol ID:IRB-P00011128                 Activation Date:  January  30, 2017                 Do Not Use After:  January  08, 2018