Randomized Controlled Trial of Talactoferrin Oral Solution

in Preterm Infants
Michael P. Sherman, MD, PhD1, David H. Adamkin, MD2, Victoria Niklas, MD3,*, Paula Radmacher, PhD2, Jan Sherman, PhD1,4,
Fiona Wertheimer, DO3, and Karel Petrak, PhD5,

Objective To evaluate the safety and explore the efficacy of recombinant human lactoferrin (talactoferrin [TLf]) to
reduce infection.
Study design We conducted a randomized, double blind, placebo-controlled trial in infants with birth weight of
750-1500 g. Infants received enteral TLf (n = 60) or placebo (n = 60) on days 1 through 28 of life; the TLf dose was
150 mg/kg every 12 hours. Primary outcomes were bacteremia, pneumonia, urinary tract infection, meningitis, and
necrotizing enterocolitis (NEC). Secondary outcomes were sepsis syndrome and suspected NEC. We recorded clinical,
laboratory, and radiologic findings, along with diseases and adverse events, in a database used for statistical analyses.
Results Demographic data were similar in the 2 groups of infants. We attributed no enteral or organ-specific
adverse events to TLf. There were 2 deaths in the TLf group (1 each due to posterior fossa hemorrhage and post-
discharge sudden infant death), and 1 death in the placebo group, due to NEC. The rate of hospital-acquired infec-
tions was 50% lower in the TLf group compared with the placebo group (P < .04), including fewer blood or line
infections, urinary tract infections, and pneumonia. Fourteen infants in the TLf group weighing <1 kg at birth had
no gram-negative infections, compared with only 3 of 14 such infants in the placebo group. Noninfectious outcomes
were not statistically significantly different between the 2 groups, and there were no between-group differences in
growth or neurodevelopment over a 1-year posthospitalization period.
Conclusion We found no clinical or laboratory toxicity and a trend toward less infectious morbidity in the infants
treated with TLf. (J Pediatr 2016;-:---).
Trial registration ClinicalTrials.gov: NCT00854633.

H
ospital-acquired infections represent the majority of diseases affecting preterm infants in neonatal intensive care units
(NICUs).1 Because hospital-acquired infections are associated with increased length of hospital stay and significant in-
creases in the cost of care, the American Academy of Pediatrics has called for strategies to reduce hospital-acquired
infections in NICUs.2,3 Among hospital-acquired infections, bacteria resistant to broad-spectrum antibiotics cause >50% of
patient-associated diseases,4 which has led to an emphasis on antibiotic stewardship.
Modified health care practices have reduced hospital-acquired infections in extremely preterm infants,2,3 but do not address
the underlying immaturity of the mucosal and systemic immune systems.5 Maternal milk is known to reduce the occurrence of
bacteremia and necrotizing enterocolitis (NEC).6,7 Biomolecules in human milk are proposed to synchronously modify the
intestinal microbiome and nascent gut and boost systemic immunity, thereby reducing susceptibility to infection.5,8 Extremely
preterm infants (birth weight <1 kg) are the most vulnerable to infection because maternal colostrum is limited immediately
after birth, or because intestinal dysmotility hinders full enteral feedings for days to weeks.
Human milk proteins enhance the development of intestinal epithelia,
facilitate a healthy intestinal microflora, establish host defenses, and heighten
mucosal defenses. We propose that the human milk protein lactoferrin partly 1
From the Division of Neonatology, Department of Child
2
Health, University of Missouri, Columbia, MO; Division
explains these beneficial effects.9,10 Commercial recombinant human lactoferrin of Neonatal Medicine, Department of Pediatrics,
(talactoferrin [TLf]) TLf became available 20 years ago.11 We found that feeding
3
University of Louisville, Louisville, KY; Division of
Neonatal Medicine, Childrens Hospital Los Angeles,
Keck School of Medicine at the University of Southern
California, Los Angeles, CA; 4Sinclair School of Nursing,
University of Missouri, Columbia, MO; and 5Agennix Inc,
Houston, TX
AE Adverse event *Current address: Prolacta, City of Industry, CA.
bLF bovine lactoferrin Current address: F.J.S. de Oro, 2835 Piso 5-2, 1425
CoNS Coagulase-negative staphylococci Capital Federal Buenos Aires, Argentina.
FDA Food and Drug Administration Funded by the National Institutes of Health (HD057744 to
IND Investigational New Drug Agennix, Inc [PI: K.P. and M.S.]). K.P. served as project
coordinator and Vice-President for Research at Agennix,
NEC Necrotizing enterocolitis Inc until 2012. The other authors declare no conflicts of
NICU Neonatal intensive care unit interest.
RCT Randomized controlled trial Portions of the study were presented at a Mead Johnson
SAE Serious adverse event Pediatric Nutrition Institute, Boston, MA, April 23-24,
2015.
TLf Talactoferrin
VLBW Very low birth weight 0022-3476/$ - see front matter. 2016 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jpeds.2016.04.084

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THE JOURNAL OF PEDIATRICS
www.jpeds.com
TLf prophylactically to neonatal rats prevented morbidity
and mortality caused by enteroinvasive Escherichia coli.12
Our research then became focused on enteral lactoferrin defi-
ciency that occurs in the early life of immature infants. We
hypothesized that administering TLf would be safe, and con-
ducted a randomized controlled trial (RCT) to assess its
safety and efficacy in very low birth weight (VLBW) infants.
Methods
In this double-blinded RTC, TLf or placebo was administered
to infants with birth weight between 750 and 1500 g starting
within 24 hours of birth and continuing through 28 days of
life (ClinicalTrials.gov: NCT00854633). We excluded infants
who had a major congenital malformation, chromosomal ab-
normality, documented prenatal or intrapartum neonatal
infection, or absence of parental consent, or were moribund
at birth. We enrolled and randomized subjects between July
1, 2009, to March 17, 2012. Hospital discharge was followed
by a 1-year outpatient follow-up period. Agennix Inc (Hous-
ton, Texas), the trial sponsor, ended the final data analyses in
December 2013.
Agennix provided TLf to 3 academic health care systems in
the US. Agennix used good manufacturing practice and sus-
pended TLf in sterile, endotoxin-free, phosphate-buffered sa-
line. The excipient served as the placebo with excellent color
matching. The Institutional Review Board for each site
approved the study. We obtained written consent from the
parents or legal guardians before 24 hours of age. Thereafter,
each institutional pharmacy randomized a subject via a cen-
tral computer system (inVentiv Clinical Solutions, Houston,
Texas). The inVentiv Web Response system also recorded
data about participants in this RCT. Agennix sponsored the
research under Food and Drug Administration (FDA) Inves-
tigational New Drug (IND) policies and procedures. The
study design included a Data Safety Monitoring Board, a
centralized serious adverse event reporting system, and peri-
odic onsite monitoring visits that verified clinical, health
care, laboratory, and radiologic data and pharmacy record
keeping.
We randomized infants to receive either TLf solution
(150 mg/mL) at a dose of 300 mg/kg/day or an identical vol-
ume of the excipient. Doses were administered every 12 hours
via nasogastric tube from days of life 1 through 28 or until
discharge, whichever occurred first. We extrapolated the
dose of TLf from lactoferrin consumed during enteral breast
milk feeding (150 mL/kg/day) with the content of lactoferrin
in human milk estimated at 2 mg/mL. In all subjects, we
administered the first dose before 24 hours of age. We
adjusted the dose at weekly intervals if the weight increased
by $10% from a previous weight.
Primary and Secondary Outcomes
The primary outcome was a significant reduction in hospital-
acquired infections, including bacteremia, pneumonia, uri-
nary tract infection, meningitis, and NEC. Our criteria
were based on Centers for Disease Control and Prevention
2 Sherman et al
Volume -
definitions for hospital-acquired infections.13 The sponsor
established strict criteria for infection, including bloodstream
infections, pneumonia, urinary tract infections, meningitis
and NEC.14 A diagnosed infection required antibiotics for
$72 hours.
Secondary outcomes were mortality, duration of hospi-
talization, time to regain birth weight, and the time to reach
full enteral feeds. Disease-related morbidities included
medically or surgically treated patent ductus arteriosus,
intracerebral hemorrhage, periventricular leukomalacia,
retinopathy of prematurity, chronic lung disease (defined
as O2 therapy at 36 weeks postconceptual age), suspected
NEC, clinical sepsis syndrome, and neonatal inflammatory
response syndrome. We defined a clinical sepsis syndrome
as a negative blood culture, but with clinical and laboratory
findings necessitating empiric antibiotic therapy. These
criteria included elevated inflammatory markers, namely
serial C-reactive protein level $1.5 mg/dL, abnormal serial
white blood cell count or an elevated immature/total
neutrophil ratio ($0.3), central thermal instability, apnea
and bradycardia, or respiratory distress. We established sus-
pected NEC as a clinical scenario that involved a cessation
of enteral feedings and initiation of antibiotics based on
gastric residuals, occult or gross blood in the stool, abdom-
inal distention, and radiographs showing dilated bowel
loops and an abnormal bowel gas pattern, but without a
sentinel loop or pneumatosis intestinalis.
Safety Assessment
We used the MedDRA system to report safety outcomes to
the FDA.15 All investigators underwent training in the use
of this grading and severity scoring system. This system re-
ports adverse events (AEs) and severe adverse events
(SAEs) on a daily basis using an FDA-accepted measurement
scale.15 The FDA mandates daily recording of clinical infor-
mation during the 28-day prophylactic period, with weekly
recording until discharge. At the 6- and 12-month postdi-
scharge visits, we collected growth measurements, including
head circumference, health outcomes, and developmental
progress using the Bayley screener III.16 If the subject did
not return, we contacted the primary care physician or par-
ents by telephone, or parents by US mail, to ascertain the in-
fants clinical status.
Agennix did not require any specific collection of clinical
findings, laboratory tests, or radiologic studies. The FDA
IND program requires information on daily weight and
abdominal circumference, vital signs, physical examination
findings, type and duration of respiratory support, O2 satu-
ration, volume and type of enteral feeding, intravenous fluids
and total parenteral nutrition volume and composition, uri-
nary output, gastric residual volumes, number and descrip-
tion of feces passed, and concomitant medications. The
study protocol collected laboratory and radiographic test
data as ordered by the supervising neonatal attending. Test
data included complete blood count, C-reactive protein,
complete metabolic and electrolyte panels, blood gas ana-
lyses, gross or occult blood in feces, and results of all
- 2016 ORIGINAL ARTICLES

radiographic studies. The cumulative weight gain from birth

and the duration of hospitalization served as biomarkers of Table I. Maternal and infant demographic data
nutritional support. TLf group Placebo group
Characteristics (n = 60) (n = 60)

Sample Size and Statistical Analysis Gestational age, wk, mean  SD* 28  6/7 28  6/7
Birth weight, g, mean  SD* 1152  206 1143  220
This RCT focused on safety. We based the original sample Birth weight 750-1000 g, n (%)
14 (23) 14 (23)
size for the Phase 1 study on the recommendations of Cohen Birth weight 1001-1500 g, n (%) 46 (75) 46 (75)
(similar to G* Power 3.1) for an ANOVA with 4 groups. Us- Small for gestational age status, n (%) 9 (15) 11 (18)
Male sex, n (%) 33 (55) 36 (60)
ing a power of 0.80, an effect size of 0.5, and an a value of Apgar score, 1 and 5 min, median z
5 and 8 7 and 8
0.05, a minimum of 48 total subjects were needed to com- Multiple births, n (%) 18 (30) 13 (22)
plete the safety phase of the study. We based the Phase 2 sam- Preterm labor, n (%) 42 (70) 41 (68)
Premature rupture of membranes, n (%) 19 (32) 21 (35)
ple size calculations on the same statistical parameters, but >12-hour rupture of membranes, n (%)
8 (13) 15 (25)
with a reduction in effect size to 0.175, resulting in a mini- Maternal antibiotics, n (%) 32 (53) 35 (58)
mum total sample of 360 subjects. Allowing for 10% attri- One or more doses of betamethasone, n (%) 48 (80) 45 (75)
Cesarean/vaginal delivery, n 49/11 48/12
tion, we estimated that 396 subjects were necessary. Race/ethnicity, n

Because of reduced funding, we decreased our sample size White 36 33

from 396 to 120 VLBW infants in 2 groups, TLf (n = 60)
and placebo (n = 60). Thus, the investigation was underpow-
ered to identify significant primary or secondary outcomes.
We entered clinical, laboratory, and radiologic findings;
disease states; and AEs into the inVentiv SAS database. We
performed statistical analyses using SAS version 9.3 (SAS
Institute, Cary, North Carolina). Descriptive statistics
included frequencies, percentages, and measures of central
tendency. We analyzed ratio-level data, such as blood count
values, C-reactive protein, and the volume of gastric resid-
uals, using an independent-samples t test. For non-
normally distributed data, we used the Mann-Whitney U
test. Nominal data were analyzed using the c2 test of inde-
pendence or the Fisher exact test for cells with a value <5.
To calculate cumulative weight gain at discharge, we used a
mixed-effects regression model that accounted for treatment,
feeding strata, birth weight, and days since birth as explana-
tory variables. Clinical significance was determined using risk
indices, namely relative risk, 95% CI, and number needed to
treat. The safety monitoring board used these measures to
ascertain TLf-related AEs and to determine primary and sec-
ondary outcomes.
Results
Table I presents demographic data for the preterm infants and
mothers associated with the clinical trial. Mothers declared
their decision regarding breast milk or formula feeding
during the consent process. The pharmacy considered each
mothers feeding decision during randomization. Thus, the
assignments were equal in the TLf vs placebo and enteral
nutrition with mothers milk and formula. Human donor
milk was not used during the trial.
The Figure (available at www.jpeds.com) presents a
CONSORT diagram of the study. Thirty-seven of 60 infants
(62%) completed the entire 28-day TLf treatment course, and
44 of 60 infants (73%) completed the entire placebo arm.
One infant assigned to the TLf arm died of brain stem
hemorrhage at 30 hours of age and was excluded from the
outcome assessment. One infant in the TLf arm died of
sudden infant death syndrome after discharge, and 1 infant in
Randomized Controlled Trial of Talactoferrin Oral Solution in Preterm Infants
African American 5 11
Asian 1 0
Multiracial 5 4
Hispanic 13 12
All comparisons had P value $.25.
*P values by the independent t test.
P values by the c2 test.
zP values by the Mann-Whitney U test.
the placebo arm died of NEC with sepsis. Among the 23
infants in the TLf arm who did not complete the entire
course of treatment, the reasons for discontinuing therapy
included discharge before the 28th day (n = 4), death (n = 1),
and medical or surgical therapy for a hemodynamically
significant patent ductus arteriosus, suspected NEC, or
enteral feeding problem (n = 18). Among the 13 infants who
did not complete the placebo course, reasons for
incompletion included discharge to home before the 28th day
(n = 13), withdrawal of consent (n = 1), and cessation of
placebo by the attending neonatologist (n = 4).
Table II (available at www.jpeds.com) shows drug
exposure and compliance. The number of doses received,
duration of drug exposure, and total drug intake were not
statistically different between the 2 study groups. Drug
compliance was 94.6% in the TLf group and 96% in the
placebo group.
At the 6-month follow-up visit, we assessed health and
developmental status in 88% of the subjects in the TLf group
and 80% of those in the placebo group. At the 12-month
follow-up visit, these percentages were 55% and 52%. Tele-
phone conversations with parents identified reasons for
missed appointments including the infants good health
and development, parents reluctance to take time off from
work, and excessive distance to travel for visits.
Safety Outcomes
Table III presents data on the incidence and types of AEs
occurring in the study population. The overall rate of at least
one treatment-emergent AE was similar in the 2 study arms.
We identified AEs related most often to preterm birth rather
than to the use of TLf or placebo. Gastrointestinal (76%),
blood and lymphatic (60%), nutritional and metabolic
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NICU stay (relative risk, 0.52; 95% CI, 0.26-0.99; P < .045).
Table III. Summary of AEs There were no cases of meningitis in either group. Two
Total, TLf Placebo P infants in the TLf group developed NEC, both of whom
Study AEs n (%) group, n (%) group, n (%) value
survived, and 1 formula-fed infant in the placebo group
At least 1 AE, n (%) 118 (98.3) 58 (97) 60 (100) .99 died from NEC.
At least 1 AE of grade 52 (43) 27 (45) 25 (42) .91
3/4/5, n (%) Table VI lists the types of bacteria that caused the
At least 1 SAE, n (%) 15 (13) 7 (12) 8 (13) .95 infections. In the TLf group, there was a reduction in
At least 1 TLf or placebo 0 0 0 - gram-positive bacterial isolates, with coagulase-negative
AE, n (%)
At least 1 AE causing drug 22 (18) 14 (23) 8 (13) .33 staphylococci (CoNS) accounting for most of these isolates.
discontinuation, n (%) In 14 infants with birth weight <1 kg, we identified no
AEs related to study cases of gram-negative bacterial infection and 2 cases of
drug, n (%)
Not related 106 (88) 53 (88) 53 (88) .94 CoNS-related bacteremia (14%). In the placebo group, 5 of
Possibly related 12 (10) 5 (8) 7 (12) .83 14 infants (36%) with birth weight <1 kg had bacteremia
AEs by degree of caused by CoNS (n = 2) or Klebsiella pneumoniae (n = 1),
severity, n (%)
Grade 1 29 (24) 14 (23) 15 (25) .94 or pneumonia caused by Klebsiella oxytoca (n = 2).
Grade 2 37 (31) 17 (28) 20 (33) .84
Grade 3 46 (38) 25 (42) 21 (35) .83 Secondary and Other Efficacy Outcomes
Grade 4 4 (3) 1 (2) 3 (5) .65
Grade 5 2 (2) 1 (2) 1 (2) .48 Tables VII and VIII (available at www.jpeds.com)
Deaths, n 3 2 1 1.0 summarize Secondary Outcomes in breast-fed and
Treatment-related 0 0 0 - formula-fed infants, respectively. Secondary outcomes,
deaths, n
including cumulative weight gain from birth and duration
MedDRA Version 14.1 defined classes, organ systems, and preferred terms. Scoring criteria are of hospitalization, did not differ by study arm or feeding
available at http://www.meddra.org/.
type. Follow-up records in the SAS database after hospital
discharge identified no abnormalities in growth or
(72%), and respiratory disorders (72%) were the most development between the TLf and placebo groups. We
commonly reported treatment-emergent AEs. These AEs proposed that TLf might reduce inflammation in treated
were often the reason for study drug or placebo infants9; however, the peak C-reactive protein level was not
discontinuation. The rate of at least 1 SAE was also similar in significantly different between the TLf group (n = 30) and
the TLf and placebo arms. All SAEs were associated with the placebo group (n = 38) (1.6  1.6 mg/dL vs
complications of very preterm birth rather than with 2.8  6.0 mg/dL, respectively).
administration of TLf or placebo. The Data Safety
Monitoring Board never halted the progression of the RCT. Discussion
Primary Outcomes To date, 4 investigative groups have published clinical trial
Table IV summarizes primary outcome data. Table V information using enteral administration of bovine lactofer-
(available at www.jpeds.com) shows the demographics of rin (bLF) to prevent late-onset sepsis and NEC during hospi-
infant having the first episode of a hospital-acquired talization of infants with birth weight #2000 g.17-20 The
infection. Compared with the placebo group, the TLf group current RCT is a Phase 1/2 trial that provides safety and pre-
had a lower risk of hospital-acquired infections during the liminary efficacy data associated with enteral administration

Table IV. First-episode hospital-acquired infections

n (%)* Statistics: TLf vs placebo group
TLf group Placebo group
Treatment types (n = 59) (n = 60) RR (% CI) NNT P value
Hospital-acquired infectionz 10 (17) 20 (33) 0.52 (0.26-0.99) 6 <.04
Blood/line infection with CoNS; 2 positive cultures required1 6 (10) 10 (17) 0.64 (0.3-1.7) 14 .52
Urinary tract infection, aseptic catheter or suprapubic tap; isolated 0 (0) 5 (8) 0.10 (0.01-1.8) 13 .09
pathogen >104 CFU/mL in urine
Tracheal aspirate, pathogen-related pneumonia + Centers for Disease 2 (3) 4 (7) 0.52 (0.1-2.8) 25 .72
Control and Prevention criteria14
Intestine, NEC Bell stage II or higher15 2 (3) 1 (2) 0.23 (0.1-1.0) 61 1.0
Infections per NICU stay
Total hospital days 3460 3446 NS
Hospital-acquired infection/1000 hospital days 2.0 4.4 0.52 (0.1-2.8) 25 .10

NNT, number needed to treat; NS, not significant; RR, relative risk.
*The number of hospital-acquired infections/total number of infants per group.
P value from c2 test for infectious comparisons; hospital-acquired infection/1000 hospital days from t test; significance P # .05.
zFirst identified episode of hospital-acquired infection in bloodstream, spinal fluid, urine, and lung fluid.

4 Sherman et al
- 2016
Table VI. Bacteria identified with first hospital-acquired infection
Bacteria/total hospital-acquired infection
TLf group
Bacterial isolate* (n/N = 8/59; 14%), n/N (%)
Gram-negative bacteria 4/8 (50)
Gram-positive bacteria 4/8 (50)
CoNS per gram-positive infectionx 3/4 (75)
*All n are based on the type of bacteria identified by Gram stain result and culture identification methods for the first episode of hospital-acquired infection.
Number of each type of infection/total number of study subjects by type (%).
zP values from the c2 test; significance P # .05.
xNumber of CoNS infections per total gram-positive bacterial infections.
of TLf. The study used a recombinant human lactoferrin pro-
duced under good manufacturing practices and with FDA
approval as an IND. This study also used the MedDRA sys-
tem to measure safety during and after administration of
TLf, an instrument used by the International Conference
on Harmonization of Technical Requirements for Registra-
tion of Pharmaceuticals for Human Use.12 The results
demonstrate the safety of the TLf molecule and provide an
initial report of efficacy related to reducing hospital-
acquired infections and possibly other noninfectious-
related outcomes.
The 4 previous studies using bLF in preterm infants re-
ported a reduced rate of infection of variable magnitude,
and 1 report using prophylaxis with bLF noted a reduction
in late-onset sepsis among infants with birth weight
<1 kg.17 In the current TLf trial, we found a 14% rate of infec-
tion in infants with birth weight <1 kg given enteral TLf vs
36% in babies given placebo. Our results are in agreement
with those reported by Manzoni et al,17 with a comparable
reduction in infection rates in extremely preterm infants.
In all studies using bLF, the biological agent was generally re-
garded as a safe food supplement. In contrast, the source of
TLf was biotechnology rather than a food supplement iso-
lated from bovine milk. Furthermore, compared with the
aforementioned RCT using bLF,17 TLf showed similar thera-
peutic efficacy as bLf in reducing gram-positive bacterial in-
fections (Table VI). We propose that this decline caused the
overall reduction in hospital-acquired infections in infants
treated with TLf compared with those treated with placebo
(Table IV).
There were no urinary tract infections in the TLf group
but some in the placebo group; however, the difference was
not statistically significant. An association between urinary
infections and NEC was reported recently.21 Because the
fecal microbiome is a microbial reservoir for urogenital
colonization, we suggest a possible relationship between
enteric prophylaxis with TLf and reduced urinary infec-
tions, and would encourage examination of this association
in upcoming clinical trials of bLF. Future studies of lacto-
ferrin prophylaxis should study the fecal microbiome,
because the microbiota present may be transferred to other
body sites. Metagenomic technology can accurately classify
the fecal translocation of pathogenic bacteria originating in
the feces.22
Randomized Controlled Trial of Talactoferrin Oral Solution in Preterm Infants
ORIGINAL ARTICLES
TLf vs placebo
Placebo group
(n/N = 20/60; 33%), n/N (%) RR (95% CI) NNT P valuez
5/20 (25) 1.6 (0.5-4.8) 8 .96
15/20 (75) 0.76 (0.3-1.8) 3 .04
11/15 (73) 0.74 (0.3-2.2) 5 .09
Finally, studies in progress should evaluate the safety of
lactoferrin by using an internationally accepted method like
MedDRA. Based on the suggested mechanisms of action
for lactoferrin,9,19 we suggest that future RCTs should also
report on differences in inflammatory biomarkers between
lactoferrin and placebo control subjects. One attractive strat-
egy may be to examine inflammation in twins who are
randomized to enteral lactoferrin vs placebo. Thoughtful ad-
aptations of the traditional RCT design may provide oppor-
tunities to test whether lactoferrin supplementation will
reduce infectious and other morbidities in VLBW infants. n
The authors appreciate the care provided by our fellow neonatologists,
neonatal-perinatal medicine fellows, neonatal intensive care nurses,
respiratory care practitioners, and pharmacists during this RCT.
Submitted for publication Jan 14, 2016; last revision received Mar 22, 2016;
accepted Apr 25, 2016.
Reprint requests: Michael P. Sherman, MD, PhD, Womens & Childrens
Hospital, University of Missouri Healthcare, Suite 206 Neonatology, 404 Keene
St, Columbia, MO 65201. E-mail: shermanmp@missouri.edu
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very low-birth-weight neonates: a randomized trial. JAMA 2009;302:
1421-8.
18. Manzoni P, Meyer M, Stolfi I, Rinaldi M, Cattani S, Pugni L, et al. Bovine
lactoferrin supplementation for prevention of necrotizing enterocolitis
in very-low-birth-weight neonates: a randomized clinical trial. Early
Hum Dev 2014;90(Suppl 1):S60-5.
19. Akin IM, Atasay B, Dogu F, Okulu E, Arsan S, Karatas HD, et al. Oral
lactoferrin to prevent nosocomial sepsis and necrotizing enterocolitis
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- 2016 ORIGINAL ARTICLES

Figure. Trial profile.

Table II. Study drug exposure and compliance

TLf group Placebo group
Dosing (n = 60) (n = 60)
Number of doses received, mean  SD 46  14 49  10
Duration of drug exposure, d, 25  7 26  5
mean  SD*
Total drug intake, mg, mean  SD 5461  4739 6221.50  4999
Compliance, %z 94.9 96.0
*Duration of drug exposure = (date of last dose  date of first dose) + 1.
Total drug exposure = sum (dose (mg/kg)  daily weight (kg)).
z% compliance = 100  (no. of complete or partial doses) O (no. of doses taken + no. of
missed doses).

Randomized Controlled Trial of Talactoferrin Oral Solution in Preterm Infants 6.e1

THE JOURNAL OF PEDIATRICS
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Table V. Patient demographic data for first episode of

hospital-acquired infection
TLf group Placebo group P
Characteristics (n = 59) (n = 60) value
Time of onset, days of life, 19  4 16  2 .40
mean  SD*
Gestational age, wk, mean  SD* 27  1 27  1 .80
Birth weight, g, mean  SD* 994  61 1003  58 .92
Infections <1000 g, n/N (%) 2 of 14 (14) 8 of 14 (57) .14
Infections >1001 g, n/N (%)z 5 of 45 (11) 6 of 46 (13) .96
*P values by the t test.
P values by the Fisher exact test.
zP values by the c2 test for independence.

Table VII. Secondary outcomes in breastfed infants

TLf group (n = 45)* Placebo group (n = 46)*
Secondary efficacy endpoints/outcomes N n (%) N n (%) P value
Suspected NEC 45 6/46 (11) 46 8/46 (15) .89
Neonatal sepsis syndrome or inflammatory response syndrome 45 3/46 (8) 46 1/46 (2) .61
Death 45 3/60 (3) 46 0/60 (2) .26
Other outcomes 45 11/46 (24) 46 11/46 (22) .89
Growth and care characteristics N Mean SD N Mean SD P valuez
Days to regain birth weight 44 44 46 55 .26
Days to full enteral feeds 37 23  13 46 20  15 .24
Days of assisted ventilation therapy 36 10  9 30 99 .76
Days of oxygen therapy 37 13  14 35 19  19 .32
Duration of hospital stay, d 45 60  31 46 59  29 .83
Cumulative weight gain at discharge, g 45 1702  20 46 1663  20 .15
*n denotes the number of events/total number of infants in a feeding group.
P values based on the c2 or Fisher exact test.
zP values based on the Mann-Whitney U test.

6.e2 Sherman et al
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Table VIII. Secondary outcomes in formula-fed infants

TLf group (n = 15)* Placebo group (n = 14)*
Secondary efficacy endpoints/outcomes N n (%) N n (%) P value
NEC scares 15 1 (8) 14 1 (7) 1.0
Neonatal sepsis syndrome or inflammatory response syndrome 15 0 (0) 14 0 (0) -
Death 15 0 (0) 14 0 (0) -
Other endpoints/outcomes 15 1 (8) 14 2 (14) 1.0
Growth and care characteristics N Mean SD N Mean SD P valuez
Days to regain birth weight 15 45 14 25 .50
Days to full enteral feeds 13 16  8 10 22  15 .58
Days of assisted ventilation therapy 8 69 10 11  11 .18
Days of oxygen therapy 13 16  10 9 29  33 .48
Duration of hospital stay, d 15 51  22 14 58  29 .82
Cumulative weight gain at discharge, g 13 1713  31 9 1710  30 .94
*n denotes the number of events/total number of infants in a feeding group.
P values based the c2 or Fisher exact test.
zP values based on the Mann-Whitney U test.

Randomized Controlled Trial of Talactoferrin Oral Solution in Preterm Infants 6.e3