Prophylactic Probiotics to Extremely Low Birth Weight Prematures (PROPEL)

• Time to establish full enteral feeds [ Time Frame: Birth to gestational week 36+0 ] [ Designated as safety issue: No ]
  The age of the infants in days when the infant receive 150 ml/kg/day via enteral feeding for the first time.
  
  

• Episodes with food intolerance [ Time Frame: Birth to gestational week 36 ] [ Designated as safety issue: No ]
  Episode with food intolerance. Retention volume> food volume given the last 2 hours (retention checked routinely every 4 hours) and/or clinical signs consistent with necrotizing enterocolitis (reduced general condition and inflated abdomen). The number of such events will also be indicated.
  
  
• Stool frequency. [ Time Frame: Recorded over three days: gw35+0- 35+2 ] [ Designated as safety issue: No ]
  
• Spitting/vomiting: the number recorded during the three days: v35 v35 +0- +2. [ Time Frame: gw 35+0-gw35+2. ] [ Designated as safety issue: No ]
  The number recorded during the three days
  
  
• Crying [ Time Frame: gw35+0-35+2 ] [ Designated as safety issue: No ]
  defined as the cries for 3 hours or more during 3 days
  
  
• Time until birth weight is regained. Specifies the number of full days the child has lived. [ Time Frame: Birth to gw 36+0 ] [ Designated as safety issue: No ]
  Specifies the number of full days the child has lived.
  
  
• Weight, height and head circumference [ Time Frame: At 14 and 28 days of life and gw 36+0 ] [ Designated as safety issue: No ]
  In this analysis, the difference in standard deviation score (delta z-scores) for weight, height and head circumference at birth and 14 and 28 days and gestational week 36+0 will be calculated. At gestational week 36+0 also absolute values will be analyzed
  
  
• Mortality [ Time Frame: Birth to gw 36+0 ] [ Designated as safety issue: Yes ]
  
• Necrotizing enterocolitis [ Time Frame: Birth to gw 36+0 ] [ Designated as safety issue: No ]
  Bell´s criteria II-III
  
  
• Sepsis [ Time Frame: Birth to gw 36+0 ] [ Designated as safety issue: No ]
  Divided into blood culture positive or clinical sepsis
  
  
• Bronchopulmonary dysplasia [ Time Frame: Gw 36+0 ] [ Designated as safety issue: No ]
  Need of oxygen or CPAP/ventilator at gw 36+0
  
  

RATIONALE Mortality and incidence of severe complications is still high among extremely premature infants. Common causes of severe complications in this population are poor nutrition, necrotizing enterocolitis (NEC), and severe infections. Feeding intolerance is also a common problem resulting in prolonged need for intravenous lines and poor nutrition. There is scientific evidence that dietary supplements with probiotics may have an effect on these manifestations.

Lactobacillus reuteri is a well studied probiotic bacterium that has been tested in several clinical studies in premature infants and older children, and the results of these studies and animal studies suggest that this bacterium may also have an effect on growth and mortality in extremely premature infants. Lactobacillus reuteri reduces colonization with pathogenic microbes, stimulates gastric and intestinal motility and shortens hospital stay in moderately premature infants. In animal models, L. reuteri also induces anti-inflammatory immune responses, reduces the symptoms of inflammatory bowel disease and the incidence of NEC. Administration of L. reuteri also improves the intestinal barrier both in human studies in children and in animal studies. Dietary supplements of L. reuteri to extremely premature infants may therefore improve feeding tolerance and nutrition and reduce the incidence of severe complications in this population.

HYPOTHESIS Premature infants with extremely low birth weight receiving daily supplements of Lactobacillus reuteri DSM 17938 will reach full enteral feeding faster compared with children receiving placebo.

STUDY DESIGN This study will be conducted as a prospective multi-center double blind placebo-controlled study in neonatal intensive care units in Sweden. In total 134 neonates with extremely low birth weight (<1000g) and gestational age <28+0 weeks will be randomized to receive either dietary supplements of Lactobacillus reuteri or placebo. Study product will be identical to the active and placebo group besides the addition of Lactobacillus reuteri (1.25 x 100 million bacteria=0.2 ml oil drops per day) in the active group. The supplementation will commence within 1-3 days after birth and will be given daily until gestational week 36+0. The infants will be followed until gestational week 36+0 and data on feeding tolerance, nutrition, growth, infections, NEC, bronchopulmonary dysplasia, death, and potential confounders will be entered in an individual study protocol. Stool, breast milk, and blood samples will be collected for analyses of possible underlying mechanisms.