European Journal of Pediatrics

, Volume 177, Issue 5, pp 733–740 | Cite as

Sequential analysis in neonatal research—systematic review

  • Sebastiano A. G. LavaEmail author
  • Valéry Elie
  • Phuong Thi Viet Ha
  • Evelyne Jacqz-Aigrain
Original Article


As more new drugs are discovered, traditional designs come at their limits. Ten years after the adoption of the European Paediatric Regulation, we performed a systematic review on the US National Library of Medicine and Excerpta Medica database of sequential trials involving newborns. Out of 326 identified scientific reports, 21 trials were included. They enrolled 2832 patients, of whom 2099 were analyzed: the median number of neonates included per trial was 48 (IQR 22–87), median gestational age was 28.7 (IQR 27.9–30.9) weeks. Eighteen trials used sequential techniques to determine sample size, while 3 used continual reassessment methods for dose-finding. In 16 studies reporting sufficient data, the sequential design allowed to non-significantly reduce the number of enrolled neonates by a median of 24 (31%) patients (IQR − 4.75 to 136.5, p = 0.0674) with respect to a traditional trial. When the number of neonates finally included in the analysis was considered, the difference became significant: 35 (57%) patients (IQR 10 to 136.5, p = 0.0033).

Conclusion: Sequential trial designs have not been frequently used in Neonatology. They might potentially be able to reduce the number of patients in drug trials, although this is not always the case.

What is known:

In evaluating rare diseases in fragile populations, traditional designs come at their limits. About 20% of pediatric trials are discontinued, mainly because of recruitment problems.

What is new:

• Sequential trials involving newborns were infrequently used and only a few (n = 21) are available for analysis.

• The sequential design allowed to non-significantly reduce the number of enrolled neonates by a median of 24 (31%) patients (IQR − 4.75 to 136.5, p = 0.0674).


Sequential analysis Clinical trial Neonatology Methodology Systematic review 



Consolidated Standards of Reporting Trials


Interquartile range


Preferred Reporting Items for Systematic Reviews and Meta-Analyses


Sebastiano A.G. Lava


Valéry Elie



Authors would like to thank Dr. Alec Villa for his assistance in linguistic revision.

Authors’ contributions

Study idea, study design: Dr. Lava, Prof. Jacqz-Aigrain

Article screening, article selection, data extraction: Dr. Lava, Dr. Elie

Statistical analysis: Dr. Lava, Ms. Ha

First draft of the manuscript: Dr. Lava

Figures: Dr. Lava

Critical revision of the manuscript: Prof. Jacqz-Aigrain, Dr. Lava

Approval of the final manuscript: Dr. Lava, Dr. Elie, Dr. Ha, Prof. Jacqz-Aigrain


Dr. Lava is the current recipient of research grants from the Fondazione Ettore e Valeria Rossi, the Batzebär foundation and the Swiss National Science Foundation.

Compliance with ethical standards

Conflict of interest

All authors declare that they have no conflicts of interest.

Ethical approval

This study is a systematic review of the literature. Therefore, it involves neither direct patient contact nor animal exposure. This article does not contain any studies with human participants or animals performed by any of the authors.


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  • Sebastiano A. G. Lava
    • 1
    • 2
    • 3
    Email author
  • Valéry Elie
    • 1
  • Phuong Thi Viet Ha
    • 1
  • Evelyne Jacqz-Aigrain
    • 1
    • 4
  1. 1.Paediatric Pharmacology and PharmacogeneticsHôpital Robert DebréParisFrance
  2. 2.University Children’s Hospital, Inselspital, University of BernBernSwitzerland
  3. 3.Division of Clinical Pharmacology and Toxicology, Institute of Pharmacological Sciences of Southern SwitzerlandEnte Ospedaliero CantonaleLuganoSwitzerland
  4. 4.University Paris DiderotSorbonne Paris-CitéParisFrance

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