Safeguarding the Brain of Our Smallest Infants Phase III (SafeBoosC)

Safeguarding the Brain of Our Smallest Children - an Investigator-initiated, Pragmatic, Open Label, Multinational Randomized Phase IIIclinical Trial Evaluating Treatment Based on Near-infrared Spectroscopy Monitoring Versus Treatment as Usual in Premature Infants

the SafeBoosC-III trial investigates the benefit and harms of treatment based on near-infrared spectroscopy monitoring compared with treatment as usual. The hypothesis is that treatment based on near-infrared spectroscopy monitoring for extremely preterm infants during the first 72 hours of life will result in a reduction in severe brain injury or death at 36 weeks postmenstrual age.

Study Overview

• Status: Completed
• Conditions: Brain Injuries; Infant, Extremely Premature; Death; Neonatal; Death, Brain
• Intervention / Treatment: Other: Modify cardio-respiratory support to avoid cerebral hypoxia; Other: Treatment as usual

Detailed Description

Background Each year, 50,000 extremely preterm infants are born in high-income countries with access to neonatal intensive care. Of these, 10,000 will die and a further 10,000 will suffer cerebral palsy or moderate-to-severe neuro-cognitive disability. Time spent outside normal cerebral oxygenation ranges (time with hypoxia or hyperoxia) is associated with poor neurological outcome in children and adults. Monitoring of cerebral oxygenation may reduce the risk of cerebral complications, but no such effects have yet been demonstrated in preterm infants in large randomised clinical trials. The recently completed SafeBoosC phase II trial was conducted at eight sites in eight European countries. 166 extremely preterm infants were randomised to visible monitoring of cerebral oxygenation by near-infrared spectroscopy (NIRS) combined with an evidence-based treatment guideline (experimental group) versus blinded NIRS and treatment as usual (control group). The trial found that NIRS monitoring in combination with an evidence-based treatment guideline successfully reduced the burden of hypoxia and hyperoxia from 81% to 36%hours during the first three days of life (p<0.001). Furthermore, the proportion of severe brain injury assessed by central reading of serial cranial ultrasound was 12.5% in the experimental group versus 23.4% in the control group, RR 0.53 (95% CI: 0.26 to 1.08). Mortality was 14% in the experimental versus 25% in the control group, RR 0.50 (95% CI: 0.29 to 1.00). No other evidence has been identified. Based on these preliminary findings, we are planning a phase III randomised clinical trial; the SafeBoosC-III trial.

Objectives The overall objective of the SafeBoosC-III trial is to investigate the benefit and harms of treatment based on near-infrared spectroscopy monitoring compared with treatment as usual. The hypothesis is that treatment based on near-infrared spectroscopy monitoring for extremely preterm infants during the first 72 hours of life will result in a reduction in severe brain injury or death at 36 weeks postmenstrual age.

Trial design The SafeBoosC-III trial will be an investigator-initiated, randomized, multinational, pragmatic phase-III clinically open trial with a two-parallel group design. Sixteen-hundred extremely preterm infants will be included within 24 months at 50 neonatal intensive care units (NICUs) across 20 countries (less than two children per month per unit). Data management and statistical analysis will be blinded.

Eligibility Eligible infants will be born before 28 weeks of postmenstrual age; decision is made to provide full life support; signed informed consent (unless the NICU has chosen to use 'opt-out' or deferred consent as consent method); and cerebral NIRS oximeter placed within 6 hours after birth.

Interventions Participants in the experimental group will be monitored during the first 72 hours of life with a cerebral NIRS oximeter, placed within six hours after birth, and treated according to an evidence-based treatment guideline. Participants in the control group will not undergo cerebral oxygenation monitoring and will be treated as usual. Each participant will be followed up at 36 weeks postmenstrual age.

Outcomes The primary outcome will be a composite of severe brain injury (cerebral haemorrhage grade III or IV, cystic periventricular leukomalacia, cerebellar haemorrhage, post-haemorrhagic ventricular dilatation or cerebral atrophy) detected on any of the serial cranial ultrasound scans that are routinely performed in these infants up to that age or death until 36 weeks of postmenstrual age.

Exploratory outcomes will be a count of the presence of bronchopulmonary dysplasia, retinopathy of prematurity stage 3+, and severe brain injury as defined in the primary outcome, as well as bronchopulmonary dysplasia, retinopathy of prematurity stage +3, necrotizing enterocolitis stage 2 or higher using the modified Bell's staging and/or focal intestinal perforation, and late-onset sepsis (>72 hours after birth) defined as treatment with antibiotics for at least five days, as isolated outcomes.

Sample size We have calculated our sample size based on the primary outcome with an alpha of 5%, a power of 90%, and a ratio of 1:1 between intervention groups. In the SafeBoosC-II trial, the proportion of trial participants in the control group with death or severe brain injury was approximately 34%. Assuming the same proportion in the SafeBoosC phase III trial control group and using 22% relative risk reduction as anticipated intervention effect, we will need to randomise a total of 1,600 participants.

Safety Oximeters approved for clinical use in newborn infants will be used. Predefined serious adverse events and serious adverse reactions will be reported separately. An independent Data Monitoring and Safety Committee will be established to monitor the safety of the trial participants during the trial.

Ethical considerations Approval from the relevant ethics committees and/or Institutional Review Boards is mandatory for every participating centre. Written parental informed consent will be obtained prior to randomisation unless the ethics committee has granted permission to use deferred informed consent or prior informed assent. The trial will be conducted in compliance with the guidelines of the Declaration of Helsinki in its latest form and of the International Conference on Harmonisation Good Clinical Practice. Procedures will be established to prevent and minimise risk of complications for participants, such as complications related to the device handling. The evidence-based treatment guideline includes only interventions that are commonly used during intensive care for this population.

Trial duration Recruitment will begin in April of 2019 and will be completed within 24 months (April of 2021).

Perspectives If the experimental intervention proves successful, we may save at least 2,000 extremely preterm infants every year from death or a life with a handicap due to brain injury in high-income countries. The ensuing health economics impact running into billions of Euros saved annually.

• Study Type: Interventional
• Enrollment (Actual): 1601
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Denmark
  • Copenhagen, Denmark, 2100
    • Rigshospitalet

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: No older than 6 hours (Child)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Infants born with postmenstrual age less than 28 weeks
• Signed informed consent, unless the NICU has chosen to use 'opt-out' or deferred consent as consent method.

Exclusion Criteria:

• Missing written parental informed consent (if the 'opt-out' method is used for consent, lack of a record that the clinical staff have explained the trial and the 'opt-out' consent process to parents and/or a record in the infant's clinical file of parents' decision to opt-out, are exclusion criteria)
• Decision not to conduct full life support
• No possibility to place cerebral NIRS oximeter within six hours after birth

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Monitoring of cerebral oxygenation; Modify cardio-respiratory support to avoid cerebral hypoxia	Other: Modify cardio-respiratory support to avoid cerebral hypoxia; modification of cardio-respiratory support based on an evidence-based treatment guideline
Other: Treatment as usual; Treatment according local guidelines and practices.	Other: Treatment as usual; Monitoring and treatment according to local guidelines and practice

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Severe brain injury or death	A composite of severe brain injury detected on any one of a series of cranial ultrasound scans that are routinely performed in these infants up to 36 weeks postmenstrual age or death at 36 weeks postmenstrual age	From birth to 36 weeks postmenstrual age

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Major neonatal morbidities	A count of the presence of major neonatal morbidities associated with neurodevelopmental impairment later in life (48): bronchopulmonary dysplasia, retinopathy of prematurity as defined below, and severe brain injury as defined in the primary outcome	From birth to 36 weeks postmenstrual age
Bronchopulmonary dysplasia	Oxygen or ventilator/continuous positive airway pressure (CPAP) requirement at the time of assessment	From birth to 36 weeks postmenstrual age
Retinopathy of prematurity	Stage 3+ and above at any time until the time of assessment	From birth to 36 weeks postmenstrual age
Necrotising enterocolitis	Stage 2 or higher using the modified Bell's staging system and/or focal intestinal perforation at any time until the time of assessment	From birth to 36 weeks postmenstrual age
Sepsis	Late-onset sepsis (>72 hours after birth) defined as treatment with antibiotics for at least five days	From birth to 36 weeks postmenstrual age

Collaborators and Investigators

• Sponsor: Gorm Greisen
• Collaborators: Copenhagen Trial Unit, Center for Clinical Intervention Research; Elsass Foundation
• Investigators: Principal Investigator: Gorm Greisen, MD, Prof, Rigshospitalet, Denmark

Publications and helpful links

General Publications

• Hyttel-Sorensen S, Pellicer A, Alderliesten T, Austin T, van Bel F, Benders M, Claris O, Dempsey E, Franz AR, Fumagalli M, Gluud C, Grevstad B, Hagmann C, Lemmers P, van Oeveren W, Pichler G, Plomgaard AM, Riera J, Sanchez L, Winkel P, Wolf M, Greisen G. Cerebral near infrared spectroscopy oximetry in extremely preterm infants: phase II randomised clinical trial. BMJ. 2015 Jan 5;350:g7635. doi: 10.1136/bmj.g7635.
• Hansen ML, Rasmussen MI, Rubin S, Pellicer A, Cheng G, Xu X, Zhaoqing Y, Zoffmann V, Greisen G. Pilot test of an online training module on near-infrared spectroscopy monitoring for the randomised clinical trial SafeBoosC-III. Trials. 2020 Apr 23;21(1):356. doi: 10.1186/s13063-020-4206-6.
• Hansen ML, Pellicer A, Gluud C, Dempsey E, Mintzer J, Hyttel-Sorensen S, Heuchan AM, Hagmann C, Ergenekon E, Dimitriou G, Pichler G, Naulaers G, Cheng G, Guimaraes H, Tkaczyk J, Kreutzer KB, Fumagalli M, Claris O, Lemmers P, Fredly S, Szczapa T, Austin T, Jakobsen JC, Greisen G. Cerebral near-infrared spectroscopy monitoring versus treatment as usual for extremely preterm infants: a protocol for the SafeBoosC randomised clinical phase III trial. Trials. 2019 Dec 30;20(1):811. doi: 10.1186/s13063-019-3955-6.
• Hansen ML, Pellicer A, Gluud C, Dempsey E, Mintzer J, Hyttel-Sorensen S, Heuchan AM, Hagmann C, Dimitriou G, Pichler G, Naulaers G, Cheng G, Vilan A, Tkaczyk J, Kreutzer KB, Fumagalli M, Claris O, Fredly S, Szczapa T, Lange T, Jakobsen JC, Greisen G. Detailed statistical analysis plan for the SafeBoosC III trial: a multinational randomised clinical trial assessing treatment guided by cerebral oxygenation monitoring versus treatment as usual in extremely preterm infants. Trials. 2019 Dec 19;20(1):746. doi: 10.1186/s13063-019-3756-y.

Helpful Links

• Trial website

Study record dates

Study Major Dates

• Study Start (Actual): June 20, 2019
• Primary Completion (Actual): December 16, 2021
• Study Completion (Actual): December 16, 2021

Study Registration Dates

• First Submitted: December 7, 2018
• First Submitted That Met QC Criteria: December 7, 2018
• First Posted (Actual): December 10, 2018

Study Record Updates

• Last Update Posted (Actual): December 20, 2021
• Last Update Submitted That Met QC Criteria: December 17, 2021
• Last Verified: December 1, 2021

More Information

Terms related to this study

• Keywords: Mortality; Cerebral oximetry; Brain injury; NIRS; Near-infrared spectroscopy; Extremely preterm; Treatment guideline
• Additional Relevant MeSH Terms: Pathologic Processes; Brain Diseases; Central Nervous System Diseases; Nervous System Diseases; Neurologic Manifestations; Wounds and Injuries; Neurobehavioral Manifestations; Craniocerebral Trauma; Trauma, Nervous System; Pregnancy Complications; Obstetric Labor Complications; Obstetric Labor, Premature; Unconsciousness; Consciousness Disorders; Coma; Brain Injuries; Death; Premature Birth; Brain Death
• Other Study ID Numbers: SafeBoosC-DP-363

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No
• product manufactured in and exported from the U.S.: Yes