Continuous Glucose Monitoring and Preterm Infants (CGM&VLBWI)

August 9, 2016 updated by: Alfonso Galderisi, University Hospital Padova

NEONATAL HYPOGLYCEMIA and CONTINUOUS GLUCOSE MONITORING: A RANDOMIZED CONTROLLED TRIAL IN PRETERM INFANTS

Neonatal hypoglycemia is associated with brain injury and impaired neurodevelopment outcomes in very low birth weight infants (VLBWI). Glycemic monitoring is usually performed by capillary or central line sampling but does not identify up to 81% of hypoglycemic episodes in preterm newborns.

The investigators aim to assess if a continuous glucose monitor (CGM) can be used to maintain euglycemia (defined as a target value 72-144mg/dl) in VLBWI.

It will be enrolled newborns ≤32 weeks gestational age and/or of birthweight ≤1500 g, within 48 hours of life, they will be randomized in two study arms, both them will wear Dexcom G4 Platinum CGM: 1) Unblinded group (UB): glucose daily intake will be modulated according to CGM (Dexcom G4 Platinum) during the first 7 days of life, alarms for hypos/hyper will be active; 2) Blinded group (B), glucose infusion rate will be modified according to 2-3 daily capillary glucose tests, alarms for hypos will be switched off. Pain at insertion will be evaluated with the validated Premature Infant Pain Profile (PIPP) scale.

The estimated numerosity is 50 patients (25 for each arm).

Study Overview

Status

Completed

Conditions

Intervention / Treatment

Detailed Description

Background - Neonatal hypoglycemia is a common event during the first week of life and has been associated to brain injuries and poor neurodevelopment. Unfortunately it may be unrecognized for several hours from its occurrence, since it is asymptomatic/poor symptomatic in newborns (Hay WW, 2009; Cornblath, 2000; Adamkin DH, 2011; Burns et al, 2008; Wong, 2013; Duvanel et al, 1999) Despite the dramatic consequences of prolonged hypoglycemia on the neonatal brain are well known, the only tool to recognize it is represented by the capillary glycemic test performed according to risk-based protocols of Neonatal Intensive Care Units (NICUs): they consider a limited window of intervention based on 2-3 glycemic tests a day (Thomas F et al, J. Diab Science Technol. 2014).

Continuous glucose monitoring systems have offered, in the last decade, a new powerful tool to recognize more hypoglycemic events in neonates than traditional monitoring. All the works developed in neonates, to date, have been aimed to evaluate the performance of the CGM devices and have been used to record the effect of medical "intervention" in the correction of hypo or hyperglycemia (Neonatal Insulin Replacement Therapy in Europe (NIRTURE, Beardsall et al, NEJM 2008; McKinlay et al, NEJM 2015) (Harris et al J Pediatrics, 2010; Beardsall et al, Arch Dis Child Fetal Neonatal 2013). The CGM has never been used to drive medical inteventions in newborns and evaluate as independent tool to improve time-in-target for glycemia.

Previous studies demonstrated that up to 81% of the hypoglycemic episodes were not detected with blood glucose measurement (Harris et al, J Pediatrics 2010). All the published studies in neonates, to date, have used Medtronic CGM systems (Medtronic, USA). No adverse effects, associated to the implant of CGM, have been reported neither in late-preterm neither in preterm newborns.

Glycemic control in terms, and moreover, in preterm newborns still represent a challenge for physicians and the wide fluctuation (both hyperglycemia and hypoglycemia) commonly observed in such population still remains difficult to be managed with traditional blood glucose monitoring (few data/day, delay of therapeutic intervention).

Aim - The study the Investigators are going to conduct is aimed to evaluate if CGM, as driver of therapeutic decisions in preterm newborns (birthweight ≤1500g, gestational age ≤32 weeks) during the first week of life, may be able to maintain "euglycemia". Euglycemia will be defined as values within the range 72-144mg/dl (4-8mmol/L)(Harris et al J Pediatrics, 2010; Beardsall et al, Arch Dis Child Fetal Neonatal Ed 2013)

Study design - Randomized Controlled Trial

  • Patients: newborns with GA ≤32weeks and/or BW≤ 1500 g. They will be enrolled within the first 48 hours of life
  • Intevention group: Unblinded CGM (DexcomG4Platinum) data to adequate daily glucose intake
  • Control group: Blinded CGM with daily glucose intake adequated according to SMBG (=2 blood glucose/day)
  • Primary Outcome: to evaluate if Unblinded CGM increases the time within "euglycemic" range (72-144mg/dl)

Materials and Methods - Dexcom G4 Platinum (Dexcom Inc, CA - USA) sensor will be applied within 48 hours from birth to the study population on the lateral side of thigh, after parents' consent collection.

All the patients will be randomized to the blinded or unblinded group before the application of CGM. Randomization will be performed using a randomization list electronically generated.

Unblinded group (intervention/open CGM group): they will wear CGM for 7 days, the alarms of CGM will be switched on and the daily intake of carbohydrates will be adapted according to CGM data. The study staff will record data every three hours in absence of hypo alarms (see below for carbs adjustment procedure).

Blinded group: they will wear CGM for 7 days, the alarms and the CGM monitor will be blinded. At least two calibrations a day, according to manufacturer instruction, will be inserted. The daily amount of carbohydrates will be decided according to blood glucose test (at least 2/day) and to recommendation of American Academy of Pediatrics (see below).

Numerosity: the estimated numerosity is 50 patients according to primary outcome. Unfortunately no data are available on this population; 10 extra patients will be recruited in case of premature interruption of recording (due to sensor detachment, malfunction, loss of the patient or interruption of monitoring due to local/systemic complication) in order to ensure a total amount of 250 days of monitoring (50% in the UB-CGM group and 50% in the B-CGM group) with a maximum amount of 350 days of monitoring. So the estimated time of monitoring is expected to be min 250, max 350 days, divided into the two groups.

Reasons for study interruption: local and/or systemic complication due to the application of device, transfer of patient to another center of care, withdrawal of consent, death, malfunction of device. Reasons for interruption of monitoring will be specified in the final report.

Carbohydrates adjustment procedure: the procedure for carbohydrates adjustment uses a worksheet described in Agus MSD, Steil G et al NEJM 2012 and adapted to NICU standard of nutrition suggested from American Academy of Pediatrics. The worksheet has been set up according to the NICU protocols in agreement with recommendation of American Academy of Pediatrics, Committee on Nutrition.

The 1st day intake is set on 6-8gr/kg of carbohydrates; a default daily increase of 1gr/kg/day in case of euglycemia is applied; such increase may variate according to the CGM data in the unblinded group or to the 2 glycemic tests performed in the blinded group in order to achieve the target as following:

i. if the average was >= 180 mg/dL decrease the calculated GIR by 1 g/kg/d ii. If the average was between 144 and 179 mg/dL do not make any adjustment iii. If the average was between 72 and 143 mg/dL check if the minimum GIR has been reached and if not increase the value to the minimum GIR for that day iv. If the average was lower than 72 mg/dL increase the rate to the either the minimum rate + 2 or the calculated rate plus 2, whichever is bigger; v. if glycemia <41mg/gl: increase of 2.8g/kg/die the GIR and perform a bolus of 2ml/kg/d of G10%.

Details of the worksheet have been described in Agus et al (NEJM2012).

Worksheet has been designed considering as follows:

Target 108,00 Low limit 72,00 High limit 144,00 Hyper Theshold 180,00 Hypo Threshold 40,00 A decrease has been considered above hyper threshold of 1g/kg/d up to a minimum GIR of 4.5g/k/d. No increase will be performed between 144 and 180mg/dl.

Data analysis will be performed as intention to treat (ITT).

Discussion: perspective and limits - Euglycemia definition remains controversial in neonatology. Even though, in our study, we have decided to adopt the NIRTURE targets (Beardsall et al, 2010) considering optimal a range from 72 mg/dl (4 mmol/L) to 144mg/dl (8 mmol/L). Values below 40mg/dl will require a G10% bolus (2ml/kg) and an increase of 2.8gr/kg of intake of carbs; values between 40 and 77mg/dl require an increase of carbs adapted to reach the middle point of the expected target. Similarly for values above the upper limit we have considered a decrease of carbs intake (minimum 4.5gr/kg/day).

The main difference between the two study groups is represented by the number of information available for the physician and, consequently, from the number of changes in glucose intake.

The use of a worksheet will allow the investigators to avoid inter-individuals variability in making infusion changes standardizing the interventions in two groups.

Actually the traditional system of monitoring of glycemia has been demonstrated to be unable to detect a significant number of glycemic variations during the daytime. Increasing the number of blood glycemic test (by heel prick) would mean to increase the number of painful procedures for the newborn with an uncertain benefit and the workload of the staff.

Disclosures: Dexcom Inc, USA will provide materials for the study as donation to the Neonatal Intensive Care Unit of University Hospital of Padua, Italy.

The study has been designed as a no-profit research project by the Principal Investigators and Collaborators of Neonatal Intensive Care Unit of University of Padua, Department of Bioengineering (University of Padua) and Boston Children's Hospital.

Dexcom Inc has not been involved in the study design and will not be involved in results evaluation.

Study Type

Interventional

Enrollment (Actual)

50

Phase

  • Phase 4

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Locations

  • Italy
      • Padua, Italy, 35128
        • Neonatal Intensive Care Unit - University Hospital of Padua
      • Padua, Italy, 35131
        • Department of Information Engineering - University of Padua
  • United States
    • Massachusetts
      • Boston, Massachusetts, United States, MA02215
        • Boston Children's Hospital

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

2 hours to 2 days (Child)

Accepts Healthy Volunteers

No

Genders Eligible for Study

All

Description

Inclusion Criteria (and/or):

  • <= 32 weeks gestation
  • birthweight <1500 g

Exclusion Criteria:

  • birthweight <500g
  • malformative syndrome
  • lack of parental consent
  • chromosomal abnormalities

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Allocation: Randomized
  • Interventional Model: Parallel Assignment
  • Masking: Single

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
Experimental: Unblinded CGM
CGM data will be "unblinded", with Hypo/hyperglycemia alarms on. Data will be recorded from CGM every three hours and intervention to adequate glucose intake will be performed to keep glycemia in normal range (72-144mg/dl) if necessary.
Device: Unblinded - CGM
Data from device will be readable and alarms on
Other: Blinded CGM
Hypo/hyper alarms are off. CGM data will be blinded. Glucose intake will be adequate according to 2-3 capillary glycemic tests per day.
Device: Blinded - CGM
Data from device will be blinded and alarms off

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
In range - time
Time Frame: 7 days (minimum 2)
Percentage of time in range 72-144mg/dl
7 days (minimum 2)

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Hypoglycemia
Time Frame: 7days
percentage of time below 40mg/dl
7days
Acute event associated to glycemic variability and/or hypoglycemia
Time Frame: 7days
Acute events (cerebral hemorrhage) and association with glycemic variability (specific patterns)
7days
Glycemic variability and hypoglycemia predictors
Time Frame: 7days
Evaluation of glycemic variability
7days
hypoglycemia prediction
Time Frame: 7days
Predictors of hypoglycemia: to individuate glycemic patterns/trends that could predict hypoglycemia
7days
Glycemic modeling
Time Frame: 7days
Creation of a glycemic modeling to predict hypoglycemia and to prevent it (see Klonoff DC et al J Diabetes Sci Technol. 2010)
7days
Pain associated to insertion of CGM respect to Pain associated to heel prick
Time Frame: 7 days
PIPP scale will be used to compare CGM vs heel prick in each subject. The scale consists of a numeric score as described by Stevens B (Clin J Pain, 1996)
7 days

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

University Hospital Padova

Collaborators

Boston Children's Hospital
University of Padova

Investigators

  • Principal Investigator: Daniele Trevisanuto, MD, University Hospital of Padua

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start

October 1, 2015

Primary Completion (Actual)

April 1, 2016

Study Completion (Actual)

April 1, 2016

Study Registration Dates

First Submitted

October 19, 2015

First Submitted That Met QC Criteria

October 21, 2015

First Posted (Estimate)

October 22, 2015

Study Record Updates

Last Update Posted (Estimate)

August 10, 2016

Last Update Submitted That Met QC Criteria

August 9, 2016

Last Verified

August 1, 2016

More Information

Terms related to this study

Keywords

Additional Relevant MeSH Terms

Other Study ID Numbers

  • 3440/AO/15

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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