Wheezing in Black Preterm Infants: Impact of Vitamin D Supplementation Strategy

Black infants face the highest rates of prematurity in the U.S. (18%), have high rates of
prematurity-associated wheezing illnesses, and tend to have lower vitamin D levels. The goal
of this [comparative effectiveness] study is to identify a vit. D supplementation strategy
that minimizes recurrent wheezing in infancy. Long recognized as important for bone health, a
growing body of evidence suggests that vit. D may play a role in the regulation and
development of many organ systems. The D pathway regulates lung inflammation and impacts
morphogenesis, structure, and cell growth and survival in bronchial smooth muscle. Vit. D
exposure has the potential to skew cytokine expression from a Th1 (less allergic) to a Th2
(more allergic) phenotype. Due to their developmental immaturity, preterm infants may be
particularly vulnerable to any positive or negative effects of vit. D supplementation on the
lung, airway, and immune system. Our preliminary data, supported by the literature, suggests
that overly aggressive vit. D supplementation may inadvertently increase wheezing in infancy
in black, but not white, preterm infants; however, vit. D deficiency could theoretically also
increase wheezing via vulnerability to respiratory pathogens. The proposed study is a
randomized clinical trial comparing the effect of two different enteral vitamin D
supplementation strategies on recurrent wheezing in infancy in 300 black infants born preterm
at 28 0/7-36 6/7 wks gestational age, a population for whom neither vit. D requirements nor
optimal vit. D serum levels have been established. The investigators will test two
strategies: (I) sustained supplementation until 6 mo. of age adjusted for prematurity, and
(II) cessation of supplementation when a minimum dietary intake of 200 IU/day is reached. The
specific aims are to characterize the effect of each strategy on (aim 1) recurrent wheezing
and (aim 2) allergic sensitization and atopy. The investigators will (aim 3) explore the
relationship between vit. D serum levels and recurrent wheezing. The investigators
hypothesize that strategy II will be more effective in promoting pulmonary health by
minimizing recurrent wheezing, allergic sensitization, and overall healthcare utilization,
and will be sufficient to prevent clinical vit. D deficiency. The investigators also
hypothesize that optimal vit. D serum levels will be lower than the norms for other
populations.

Inclusion criteria:

1. 28 0/7-36 6/7 weeks gestational age (GA) at birth;

2. family identifies the child as black or African American;

3. < 28 days of supplemental oxygen (subsequent oxygen therapy for < 72 hrs for a brief
subsequent illness or surgery will be allowed);

4. admitted to a participating site NICU, special care nursery, transitional care
nursery, or well-baby nursery as a neonate; and

5. < 40 weeks corrected GA at enrollment.

Exclusion criteria:

1. BPD (> 28 days of supplemental oxygen);

2. pre-existing diagnosis of moderate to severe osteopenia of prematurity and/or alkaline
phosphatase > 700;

3. history of fracture;

4. gastrointestinal surgery, including for NEC;

5. known gastrointestinal malabsorption;

6. major congenital anomaly;

7. congenital pulmonary or airway disorder (e.g., cystic fibrosis, tracheomalacia,
swallowing disorder, bronchopulmonary sequestration);

8. documented wheezing or stridor prior to enrollment;

9. previous vit. D supplementation with > 400 IU/day;

10. family plans to move more than 60 miles from CWRU or other pre-defined radius at other
sites;

11. baseline hypo- or hypercalcemia, hypo- or hyperphosphatemia; and

12. baseline 25(OH) D level < 10 ng/ml.