Early oxytocin treatment in infants with Prader-Willi is safe and is associated with better endocrine metabolic and behavior outcomes.

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Marion VALETTE, Gwenaelle DIENE, Mélanie GLATTARD, Julie CORTADELLAS, and 9 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4611289/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 01 Mar, 2025 Read the published version in Orphanet Journal of Rare Diseases → Version 1 posted 5 You are reading this latest preprint version Abstract Background: Oxytocin (OT) plays an important role in modulating behavior social interactions and feeding. Prader-Willi syndrome (PWS), a rare genetic neurodevelopmental disorder, is a model of hypothalamic disorder including OT dysfunction. We previously showed that infants with PWS who received an early short course (7 days) of intranasal OT treatment improved their oral and social skills. We aim to document long-term tolerance and effects of early intranasal OT treatment on the disease trajectory. We then performed a comparative clinical trial including the 17 children who received OT as infants in our previous study and compared them to 17 PWS non-exposed children at 3 to 4 years old. Primary endpoint was the total communication score on the Vineland adaptive behavior scale version II (VABS-II). Secondary endpoints were the other domains of VABS-II, behavior scored by Childhood Behavior Check-list, feeding skills, endocrine and metabolic issues, and brain connectivity on functional magnetic resonance imaging. Results: We documented long-term safety of early OT treatment. The VABS-II communication score was not different between the two groups defined as OT-exposed and non-exposed groups while a trend towards higher socialization score was found in the OT-exposed children (p=0.06). Circulating IGF-1 and HDL cholesterol were significantly higher in the OT-exposed group (p<0.05). OT-exposed children had normal acylated ghrelin levels which are lower than those observed in non-exposed children (p=0.06) and display higher connectivity of the orbitofrontal cortex brain region. Conclusion: Early OT treatment in infants with PWS is safe up to 3 to 4 years age. OT-exposed children display better social, endocrine and metabolic outcomes. This study documents for the first time in human the biological window of opportunity of early OT treatment that may change the trajectories of PWS condition. Trial Registration : Clinical trial NCT03081832 Retrospectively registered https://clinicaltrials.gov/search?cond=NCT03081832 Prader-Willi syndrome oxytocin infants long-term effects behavior metabolism brain connectivity Figures Figure 1 Figure 2 Figure 3 Figure 4 INTRODUCTION Oxytocin (OT) plays an important role in modulating social interactions, mother-infant bonding and feeding. A reduced number and volume of OT neurons in the paraventricular nucleus were reported in postmortem human hypothalamic tissue from patients with Prader-Willi syndrome (PWS) ( 1 ). It is now acknowledged that the PWS phenotype is explained by impaired hypothalamic development and function including OT and ghrelin systems ( 2 ). PWS is clinically characterized by a specific developmental trajectory involving neurodevelopmental, nutritional, endocrine and metabolic, and behavioral dimensions ( 2 , 3 ). PWS results from the loss of expression of paternally inherited imprinted genes of chromosome 15 at position q11- q13 due to a paternal microdeletion, a maternal uniparental disomy (mUPD), an imprinting defect or a translocation involving this region ( 2 , 4 , 5 ). Nowadays around 50% of the newborns display a microdeletion. The non-deletion genotype subtype comprises newborns with mUPD (around 45%) and imprinting defect (around 5%). Our previous phase 2 study OTBB2 (NCT 02205034) showed that 16/18 infants with PWS younger than 6 months who received a short course of intranasal OT for 7 days improved their oral and social skills including mother-infant interactions after the last OT administration ( 6 ). Circulating acylated ghrelin (AG) levels and the connectivity of the right superior orbitofrontal network were significantly increased ( 6 ). These results reproduced the preclinical data in Magel2 knock out (KO) mice, a mouse model obtained after inactivating Magel2 gene, one maternally imprinted gene of the PWS chromosomal region, showing that a single OT injection before the first 5 hours of life rescued 100% of the Magel2 KO pups from early death by restoring normal sucking activity ( 7 ). These rescued pups displayed normal socialization and increased memory and learning skills as adults ( 8 ). In the current clinical trial, we want to evaluate the long-term tolerance and effects of 7 days of intranasal OT treatment in infants (< 6 months of age) who participated to the OTBB2 study by comparing them at 3 to 4 years of age to a group of age-matched children with PWS not treated with OT. This study aims to document for the first time in human long-term tolerance of early OT treatment and if it changes the course of the disease up to 4 years. METHODS STUDY POPULATION A detailed description of the population is shown in Table 1 . Thirty-four children, 47% of female and 41% with deletion genetic subtype were included in this comparative study. Children belonged to one of the two groups, OT-exposed and non-exposed (17 children per group). These two groups were not statistical different regarding birth data, social status, family composition and schooling. In the whole group, median age was 3.8 years [3.0;4.3], BMI-Z-score was 0.08 [-1.79;6.31]. All children received GH treatment. All children were followed in dedicated PWS centers except for one OT-exposed child due to extreme poverty of the family with high social deprivation score. Table 1 Characteristics of the population. Variable OT-exposed (n = 17) Non-exposed (n = 17) All (n = 34) Age (yrs) 3.8 (3.1;4.2) 3.8 (3.0;4.3) 3.8 (3.0;4.3) Sex Female n (%) 7 (41%) 9 (53%) 16 (47%) Genetics Deletion n (%) Non-deletion n (%) - mUPD n (%) - Imprinting defect n (%) 6 (35%) 11 (65%) 9 (53%) 2 (12%) 8 (47%) 9 (53%) 9 (53%) 0 14 (41%) 20 (59%) 18 (53%) 2 (6%) Auxological data - body composition Weight (kg) Weight (DS) Height (cm) Height (DS) BMI kg/m 2 BMI (Z-score) BMI Z-score ≥ 2 Head circumference (cm) Head circumference (SDS) Body fat mass (%) Body lean mass (%) 15.4 (12.2;28.4) 0.7 (-1;10,7) 98.5 (92.5;108) 0.8 (-1.2;3.9) 15.9 (14.1;26.3) 0.13 (-1.5;6.31) 2 (12%) 49 (46.5;53) (n = 16) -0.35 (-2.5;2.7) (n = 16) 22 (10;65) (n = 17) 75 (32;85) (n = 17) 14.6 (13;19.6) 0.6 (-1.1;4.8) 96 (90.5;107) 0.5 (-1.4;4.3) 15.4 (13.8;21.7) -0.35 (-1.79;4.23) 2 (12%) 50 (48;52.5) (n = 17) -0.31 (-1.9;1.25) (n = 17) 24.5 (8;40) (n = 16) 71 (57;88) (n = 16) 15.2 (12.2;28.4) 0.6 (-1.1;10.7) 97.9 (90.5;108) 0.6 (-1.4;4.3) 15.8 (13.8;26.3) 0.08 (-1.79;6.31) 4 (12%) 50 (46.5;53) (n = 33) -0.31 (-2.5;2.7) (n = 33) 22 (8;65) (n = 33) 73 (32;88) (n = 33) GH treatment % of treated Dose at start GH treatment (µg/kg/day) Current GH dose (µg/kg/day) Age at start GH treatment (months) % with at least 2 years of treatment 100% 26 (15;41) 27.6 (15.2;41.4) 10.0 (7.2;12.4) 100% 100% 25 (8;52) 28.6 (6.8;51.5) 13.2 (7.5;30.3) 94% 100% 26 (8;52) 28.1 (6.8;51.5) 10.6 (7.2–30.3) 97% Psychosocial and family data Number of siblings Couple n (%) Schooling n (%) Social vulnerability score (EPICES)* 0 (0;2) 12 (71%) 12 (71%) 16.6 (0;100) (n = 17) 1 (0;3) 14 (82%) 14 (82%) 16.9 (0;73) (n = 16) 1 (0;3) 26 (77%) 26 (77%) 16.6 (0;100) (n = 33) Birth data Term (WA) Premature birth n (%) Cesarean delivery n (%) Weight (SDS) Length (SDS) Nasogastric tube feeding (NGT) n (%) Duration of NGT (days) 39 (30–41) 3 (18%) 9 (53%) (n = 17) -1.7 (-2.9;-0.3) (n = 17) -0.9 (-2.5;0) (n = 17) 15 (88%) 120 (14–195) 39 (32–41) 3 (18%) 10 (59%) (n = 16) -1.7(-2.3;0) (n = 16) -1.0 (-2.6;0) n = 16) 13 (76%) 31 (2-210) 39 (30;41) 6 (18%) 19 (56%) (n = 33) -1.7 (-2.3;0) (n = 33) -0.9 (-2.6;0) (n = 33) 28 (82%) 85 (2-210) Results are presented as n (%) or median (min-max) by groups and in all children. There was no statistical difference between the two groups regarding all the parameters of the table. *The maximum score is 100, the cutoff of 30 was used to define social deprivation. STUDY PROTOCOL This single-center clinical trial compared the adaptive functioning, behavior and development, as well as feeding and social skills, endocrine, metabolic and safety issues, of 3- to 4-year-old PWS children who composed the 2 groups mentioned above. The OT-exposed group comprises 17 children who participated as infants in the OTBB2 study. The OTBB2 study was an open-label phase I/II escalating dose study with three groups of six infants with PWS, each group receiving the same dose which increased from group 1 to group 3 as described: OT 4 IU every other day, every day, twice a day for a total duration of treatment of 7 days. Children of the non-exposed group were aged-matched (with a maximum difference of plus or minus 3 months) with children of the OT-exposed. All children were admitted for a single 3-day visit in the Hospital hosting the French reference center for PWS in Toulouse. The complete study protocol is available at https://www.chu-toulouse.fr/IMG/pdf/final_protocole__ot2suite_v1.6_22032017-en.pdf and details of inclusion and exclusion criteria are detailed below. Inclusion/Exclusion criteria Among the 18 patients included in the OTBB2 study, one was lost to follow-up; the 17 remaining patients were included in this current study. One patient combining severe social economic deprivation regarding the EPICES score (> 50) and poverty, defined as extreme deprived conditions of life confirmed by the clinical team, was excluded of the Vineland socialization domain analysis because both conditions have a severe impact on care, social adaptive skills and behavior. Outcomes and data collected Adaptive functioning : the primary endpoint was the score in the communication domain of the Vineland adaptive behavior scale version II (VABS-II) ( 9 ). The VABS-II evaluates adaptive functioning in four domains: Communication, Socialization, Daily Living Skills and Motor Skills expressed in scores and categorized in adequate /moderately low /low. Age equivalent scores and standard scores (mean (M) = 100; standard deviation (SD) = 15) are provided for each domain. The other subscores of the VABS-II were analyzed as secondary endpoints as were the following evaluations. Behavior : behavior was assessed with the Child Behavior Check List (CBCL) using its total T score and 14 subscores ( 10 ). Feeding skills : a dynamic videofluoroscopy of swallowing (VFSS) was performed and scored with a chart including the analysis of the five phases of swallowing. Eating behavior was assessed by a questionnaire used in routine care in our center. It was completed by the pediatrician during an interview with the parents, with 5-point Likert scale responses (Supplementary Table 1). Growth and development : children were measured and weighed during the study visit. Development was assessed by the Bayley Scale of Infant and Toddler Development version III (BSID-III), which included cognitive, receptive language, expressive language, fine motor, and gross motor scores ( 11 ). Endocrine and metabolic evaluations : sampling for hormone and metabolic assays: Measurements of IGF-1, thyroid hormones, glycaemia, insulin and lipids were performed as routine evaluations. Plasma concentrations of acylated ghrelin (AG), unacylated ghrelin (UAG) and OT were measured as previously described ( 6 ). We then compared the ghrelin data with data from age-matched healthy controls from our previous studies ( 12 , 13 ). Brain connectivity analysis during resting state using functional MRI (fMRI) : the children lay supine and were instructed to relax and keep their eyes closed, but not to sleep. fMRI preprocessing and statistical analyses are described in the supplementary methods. We chose to study the default mode network (DMN) which has frequently been studied and the orbitofrontal cortex network (superior, median and inferior) as in the OTBB2 study ( 6 ). To reveal the areas where significant connectivity change occurred, we set up the threshold for the Statistical Maps at p < 0.005 voxel-wise and we used a threshold for cluster extent of P < 0.05 corrected for multiple comparisons across the whole brain. Comorbidities : sleep disorders and orthopedic problems reported in children medical files were collected. Evaluation of tolerance : tolerance was assessed by recording vital signs, physical examination sign, laboratory parameters and adverse events (AE); Evaluation of social deprivation : the EPICES score (Evaluation of the Deprivation and Inequalities of Health in Healthcare Centers) is a self -questionnaire validated in France ( 14 , 15 ) that evaluates the social deprivation of the family as defined by limited access to society’s resources due to poverty, discrimination, or other disadvantages. The score ranges from 0 to 100 with a threshold of > 30 defining social deprivation. Statistical analysis Comparisons between OT-exposed and non-exposed group were performed. Results for all variables, including each item of the questionnaires, were summarized by group using descriptive statistics or frequency/percentage, as appropriate. A parametric approach (Student t-test) or a non-parametric approach (Mann-Whitney) according to the normality/non-normality distribution was used to compare groups. Subgroups statistical analysis was done using an analysis of variance (ANOVA). The model included group (treated vs. untreated) and age group (1st, 2nd, and 3rd terciles) as fixed effects. Subgroup analysis was performed to explore the group effect within two levels of genetic diagnosis (deletion and non-deletion). When differences were found between the two genetics subtypes within OT-exposed vs non-exposed groups they were mentioned in the result section. Differences in the proportions of normal and abnormal patients, defined by thresholds, between the OT-exposed and non-exposed groups were analyzed using a Cochran-Mantel-Haenszel test with age group as the controlling factor. Statistical analysis was performed using SAS® Enterprise Guide software, version 7.1 (SAS Institute, Cary, NC, US) and Stata version 11.2 (Stata Corp, College Station, TX). The statistical significance threshold was set at 0.05. RESULTS Adaptive behavior Primary endpoint: VABS-II communication domain The mean total communication score (74 in OT-exposed vs. 75 in non-exposed) and subscores were not significantly different between the two groups (Figs. 1 A and 1 B). Secondary endpoints Socialization domain This domain comprises three subscores: coping skills, interpersonal relationships and play leisure. We found a trend for higher mean total socialization score in the OT-exposed group excluding the child with social deprivation and extreme poverty (76 in OT-exposed vs . 70 in non-exposed, p = 0.063) adjusted on age (Figs. 1 C and 1 D) compared to the non-exposed group. The total socialization score was adequate in 24% vs. 6% in the OT-exposed vs. non-exposed group, (p = 0.098). In the non-deletion genetic subtype groups, the interpersonal relationships sub-score was adequate in 29% in the OT-exposed children vs none in the non-exposed children (p = 0.020). Other domains of the VABS-II The two other domains of the VABS-II (daily living skills and motor skills) were not significantly different between the OT-exposed and non-exposed groups using total scores or subscores. Behavior The mean total score of the CBCL was not significantly different between the two groups when adjusted on age (52 in the OT-exposed vs. 55 in the non-exposed group, p = 0.37). The internalizing problems subscore was normal in 94% vs. 65% (p = 0.04) and the emotionally reactive subscore was normal in 94% vs. 71% (p = 0.08) in the OT-exposed vs. the non-exposed group respectively. Figure 2 shows the forest plot comparing the difference between the deletion vs. non-deletion genetic subtype groups within the OT-exposed and the non-exposed groups. In the deletion subtype group we found statistically significant differences or a trend in many subscores between the OT-exposed and non-exposed groups with better subscores in the OT-exposed children (Fig. 2 ). Oral skills The total VFSS score was abnormal in all children. No statistically significant difference was observed between the OT-exposed and non-exposed groups for the mean total score or the distribution of children with normal and abnormal subscores, although there were trends for more normal subscores in the OT-exposed group (see Supplementary Table 2). Feeding behavior Mean total score of the feeding behavior questionnaire was similar in the OT-exposed and non-exposed groups (11.6 vs 13.3, p = 0.5). We found a significant difference only for question 13, in the non-deletion genetic subtype groups (interaction treatment*genotype, p = 0.02) with 55% of the non-exposed children requiring food access control vs no children in the OT-exposed group. Development The BSID-III scores were not different between the two groups. Most of the children were classified as abnormal (see Supplementary Fig. 1). Comorbidities Comorbidities are listed in Table 2 . Endocrine and metabolic disorders : all children received GH treatment at the same recommended dose and median IGF-1 levels were in the normal range with significantly higher values in the OT-exposed group compared to the non-exposed group (198 ng/mL vs. 132 ng/mL, p = 0.01). Median HDL-cholesterol levels were significantly higher in the OT-exposed group compared to the non-exposed group (0.52 g/L vs . 0.46 g/L, p = 0.02). There was a trend for higher T4L in the OT-exposed group which was related to the higher frequency of L-Thyroxine treatment in this group. Table 2 Comorbidities presented by the children in each group and comparison between groups Variable OT-exposed (N = 17) Non-exposed (N = 17) P-value Endocrine and metabolic comorbidities IGF-1(ng/mL) Free Thyroxine (ng/L) Treatment by L-Thyroxin n (%) Dosing (µg/d) HDL Cholesterol (g/L)** LDL Cholesterol (g/L) VLDL Cholesterol (g/L) Total Cholesterol (g/L) Triglycerides (g/L) Glycemia (g/L) Insulinemia (mIU/L) HOMA-IR (min-max) 198 (36–267) 13.2 (10.4–15) 10 (59%) 17.5 (10–50) 0.52 (0.38–0.82) 1.05 (0.67–1.95) 0.15 (0.08–0.22) 1.71 (1.27–2.59) 0.73 (0.39–1.12) 0.76 (0.6–1.08) 5.1 (1.9–18.3) (N = 15) 0.9 (0.4–4.9) 132(26–266) £ 12.2 (9.5–15.3) 5 (29%) 20 ( 10 – 25 ) 0.46 (0.33–0.6) 1 (0.36–1.8) 0.14 (0.1–0.28) 1.61 (1.02–3.48) 0.7 (0.5–1.4) 0.74 (0.52–0.9) 4.8 (1.9–12.2) (N = 15) 1 (0.3–2.3) 0.01 0.07 NS NS 0.02 NS NS NS NS NS NS NS Sleep respiratory disorders (polysomnography before GH) Apnea hypopnea index (AHI) Obstructive apnea index (OAI) Central apnea index (CAI)* % of children with ICA ≥ 1 N = 13 2.9 (0.5;15.5) 0 (0;9.9) 0.5 (0;4.4) (N = 13) 46% N = 12 3.5 (0;56.8) 0 (0;2.3) 2.3 (0 ;18.7) (N = 12) 83% NS NS 0.06 0.03 Scoliosis n (%) Age at diagnosis (yrs) Cobb angle (°) 6 (35%) 1.75 (1.05–2.11) 30 (15–56) (N = 5) 5 (29%) 1.69 (1.09–2.19) 29 (17–80) (N = 3) NS Results are presented as n (%) or median (min-max) by groups and in all children £ n = 16 *logistical regression adjusted for age. Ghrelin levels: The OT-exposed group showed a trend for lower AG levels vs. the non-exposed group (172 ng/mL vs. 257 ng/mL, p = 0.06) with no significant difference in UAG and a trend for a lower AG/UAG ratio (1.37 vs. 1.91, p = 0.09) (Fig. 3 ). When compared to a healthy control group of same age range, the OT-exposed group had similar AG levels (172 ng/mL in OT-exposed group vs. 115 ng/mL in healthy controls) whereas UAG was significantly higher (130 ng/mL vs. 76 ng/mL, p = 0.007) with no difference in the AG/UAG ratio. The non-exposed group had significantly higher levels of both AG (257 ng/mL vs. 115 ng/mL, p = 0.03) and UAG (127 ng/mL vs. 76 ng/mL, p = 0.005) compared to the healthy control group adjusted for age with no difference in the AG/UAG ratio. Sleep disorders : patients underwent polysomnography before the start of GH treatment at a median age of 8.5 months (range 5.1–10.7 months) in the OT-exposed group (N = 13) vs. 12.6 months (range 7.3 to 26) in the non-exposed group (N = 12). Forty-six percent of OT-exposed children had central apnea (central apnea index (CAI) > 1) before initiating GH treatment vs. 83% of the non-exposed children (p = 0.03). We found a trend towards a lower median CAI adjusted on age in the OT-exposed group vs. the non-exposed group (0.5 vs. 2.3/hr respectively, p = 0.06). No difference was observed after GH treatment. Scoliosis : no difference was observed regarding the occurrence of scoliosis: 35% in the OT-exposed group vs . 29% in the non-exposed group. Safety Overall, three subjects in the OT-exposed group (17.6%) and seven subjects in the non-exposed group (41.2%) reported at least one adverse event during the study (see Supplementary Table 3), none of them related to the intranasal OT treatment. Comparison of body measures, vital signs, and standard laboratory parameters between the two groups OT-exposed and the non-exposed group, showed no evidence of any negative effect of OT treatment. Circulating OT levels No difference in circulating OT levels was found between the two groups: 0.44 ng/L in the OT-exposed group vs. 0.45 ng/L in the non-exposed group. Brain fMRI Among the 18 patients who underwent the fMRI, only 10 (6 in the OT-exposed group and 4 in the non-exposed group) were able to stay motionless during fMRI acquisition and completed the whole experiment. In the DMN analysis, the OT-exposed group showed higher connectivity of the right hippocampus, precuneus and the medial frontal cortex regions (p < 0.005) (Fig. 4 A 4 C). In the orbitofrontal component analysis, the OT-exposed group showed a higher connectivity in the inferior occipital, precentral, medial frontal and cuneus regions (p < 0.005) (Fig. 4 B 4 D). There was a negative correlation within the whole group between the VABS-II total score of socialization and the connectivity of the parahippocampus (p = 0.036) (Fig. 4 E) and a negative correlation with the circulating UAG level and the connectivity of the frontal cortex (p = 0.022) shown in (Fig. 4 F). DISCUSSION This clinical trial allowed us to document for the first time the good long-term tolerance of early OT treatment of infants with PWS who participated to the OTBB2 study( 6 ) and to compare the characteristics and the severity of the disease in these children at 3 to 4 years with an age-matched non-exposed group of PWS children. We did not find a statistically significant difference between the two OT-exposed and non-exposed groups for adaptive skills of the communication domain using the VABS-II, which was the primary endpoint of our study. We found a strong signal regarding socialization domain, with a trend toward higher score and more children with adequate socialization scores in the OT-exposed group compared to the non-exposed group. This long-term effect of OT on social skills has been demonstrated in the Magel2 gene inactivated mouse model and is consistent with the known effect of OT in bonding and in setting the network for social recognition ( 16 ). Regarding the comprehensive evaluation of behavior using the CBCL which is widely used in PWS, we did not find a significant difference between OT-exposed and non-exposed groups. Interestingly in the deletion genetic subtype groups we found better outcome in the OT-exposed vs non-exposed children in most of the subscores. The influence of genetic subtype on the effect of OT treatment was also reported in a 3 months study in children with PWS (age 3–11 years) ( 17 ). This study showed significant improvement of Dykens Hyperphagia questionnaire ( 18 ) and global behavior score after OT treatment vs placebo only in the deletion group of children ( 17 ). Conversely in our study the differences between the OT-exposed and non-exposed group regarding the need for control access for food was only observed in the non-deletion genetic subtype children. For the other endpoints, we did not find the influence of the genetic subtype. Oral skills analyzed by VFSS were not significantly different between the two groups but we observed a trend for more frequently adequate swallowing pharyngeal initiation and protection of respiratory airway in the OT-exposed group. Interestingly we found significant differences between the two OT-exposed and non-exposed groups on endocrine and metabolic comorbidities. Although all children received GH treatment at the same dose, the OT-exposed group displayed significantly higher levels of IGF-1 suggesting greater GH sensitivity, which may be explained by better metabolic outcome as HDL-cholesterol levels were also significantly higher in the OT-exposed group. Hyperghrelinemia is a cardinal metabolic marker of PWS. As a group, patients with PWS display high AG and UAG levels at all ages ( 19 ). We previously showed normalization of AG levels in the OTBB2 trial ( 6 ) and we reported in this study that this effect persists up to 4 years of age. The results suggest that early OT treatment may prevent the switch in the ghrelin system observed in PWS ( 12 , 19 ). The significant differences observed in endocrine and metabolic trajectories are unexplained but are comparable with the results obtained by attenuating leptin effect during early life that improves lifelong metabolic regulation in postnatally overnourished mice ( 20 ). Central apnea is a common feature in infants and children with PWS ( 21 ). Our study showed that the OT-exposed children displayed less frequently central apnea before the start of GH treatment than the non-exposed children, which suggests that early OT treatment may also prime the autonomic system linked with respiratory control. One study reported a positive effect of OT administration on sleep respiratory disorders in non-PWS adult obese patients and showed a reduction of the frequency of hypopneas and the duration of apneas and hypopneas ( 22 , 23 ). The current study showed differences between the OT-exposed group and non-exposed group in the brain connectivity of regions involved in neurodevelopment which were identified in the OTBB2 study ( 6 ), thereby documenting a long-term effect of OT on brain plasticity particularly in regions involved in the regulation of socialization and feeding, such as the parahippocampus and the frontal cortex ( 24 , 25 ). As a whole, our study paves the way to demonstrate the long-term effects of early OT treatment during a post-natal critical period in humans ( 26 ). Children of the OT-exposed group are now 9 to 10 years old. They are routinely followed in our center and we confirm excellent long-term tolerance of early OT treatment (data not shown). We recently completed a phase III European study comprising 52 PWS infants who received a longer course of OT treatment (1 or 2 months). These OT treated infants will be followed yearly until 4 years of age to confirm the good long-term tolerance and will be compared to non-exposed children in order to confirm our current data with a longer duration of early OT exposition of infants. Strength and limitations of the study: although the study population was small due to the rarity of the disease, the evaluations including biological and endocrine aspects were performed in the same expert center with patients coming from the whole country. In conclusion, our comparative study demonstrated the long-term safety of early short course (7 days) of intranasal OT treatment in infants with PWS and better outcomes at 3 to 4 years regarding behavior, endocrine and metabolism, as well as differences in brain regions of interest connectivity. This study documents for the first time in human the postnatal critical period that offers a window of opportunity to implement OT treatment to change the trajectories of the disease. Declarations Ethics approval and consent to participate: The clinical study was approved by the Comité de Protection des Personnes Sud-Ouest et Outremer I. Written informed consent was provided by the parents of the children. Consent for publication: All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work. Availability of data and materials: The data that support the findings of this study are available from CHU of Toulouse but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of CHU of Toulouse. Competing interests: The authors declare that they have no competing interests Funding: Funding was obtained from Prader-Willi France Association. The Start-up OT4B funded the statistical analysis made by the clinical research organization Atlanstat. Authors' contributions: Dr Marion Valette, Prof Maithé Tauber, Dr Gwenaelle Diene, Mrs Catherine Molinas and Dr Catherine Arnaud conceptualized and designed the study, drafted the initial manuscript, and critically reviewed and revised the manuscript. Mrs Melanie Glattard, performed the Vineland study and drafted the initial manuscript and critically reviewed and revised the manuscript. Dr Sophie Çabal and Dr Gregoire Benvegnu drafted the initial manuscript, and critically reviewed and revised the manuscript. Mrs Julie Cortadellas and Dr Sandy Faye, designed the data collection instruments, collected data, and critically reviewed and revised the manuscript. Prof Jean Pierre Salles critically reviewed and revised the manuscript for important intellectual content. Dr Kader Boulanouar and Prof Pierre Payoux designed the brain MRI studies, wrote this part of the manuscript and reviewed the entire manuscript. Acknowledgements: We thank Cathy Brochado for collection of data and Camille Lassale for post-hoc statistical analyses. References Swaab DF, Purba JS, Hofman MA. Alterations in the hypothalamic paraventricular nucleus and its oxytocin neurons (putative satiety cells) in Prader-Willi syndrome: a study of five cases. J Clin Endocrinol Metab. 1995;80(2):573-9. Tauber M, Hoybye C. Endocrine disorders in Prader-Willi syndrome: a model to understand and treat hypothalamic dysfunction. Lancet Diabetes Endocrinol. 2021;9(4):235-46. Miller JL, Lynn CH, Driscoll DC, Goldstone AP, Gold JA, Kimonis V, et al. Nutritional phases in Prader-Willi syndrome. Am J Med Genet A. 2011;155A(5):1040-9. Cassidy SB, Schwartz S, Miller JL, Driscoll DJ. Prader-Willi syndrome. Genet Med. 2012;14(1):10-26. Buiting K, Cassidy SB, Driscoll DJ, Gillessen-Kaesbach G, Kanber D, Tauber M, et al. Clinical utility gene card for: Prader-Willi Syndrome. Eur J Hum Genet. 2014;22(9). Tauber M, Boulanouar K, Diene G, Cabal-Berthoumieu S, Ehlinger V, Fichaux-Bourin P, et al. The Use of Oxytocin to Improve Feeding and Social Skills in Infants With Prader-Willi Syndrome. Pediatrics. 2017;139(2). Schaller F, Watrin F, Sturny R, Massacrier A, Szepetowski P, Muscatelli F. A single postnatal injection of oxytocin rescues the lethal feeding behaviour in mouse newborns deficient for the imprinted Magel2 gene. Hum Mol Genet. 2010;19(24):4895-905. Meziane H, Schaller F, Bauer S, Villard C, Matarazzo V, Riet F, et al. An Early Postnatal Oxytocin Treatment Prevents Social and Learning Deficits in Adult Mice Deficient for Magel2, a Gene Involved in Prader-Willi Syndrome and Autism. Biol Psychiatry. 2015;78(2):85-94. Sparow SS, Cicchetti DV, Balla DA. Vineland-II, Echelles de comportement adaptatif de Vineland. 2nd edition ed2015. Achenbach TM, Rescorla LA. Manual for the ASEBA School-Age Forms & Profiles: Burlington, VT: University of Vermont, Research Center for Children, Youth, & Families; 2001. Bayley N. Bayley Scales of Infant and Toddler Development. 3rd edition ed2006. Beauloye V, Diene G, Kuppens R, Zech F, Winandy C, Molinas C, et al. High unacylated ghrelin levels support the concept of anorexia in infants with prader-willi syndrome. Orphanet J Rare Dis. 2016;11(1):56. Kuppens RJ, Diene G, Bakker NE, Molinas C, Faye S, Nicolino M, et al. Elevated ratio of acylated to unacylated ghrelin in children and young adults with Prader-Willi syndrome. Endocrine. 2015;50(3):633-42. Labbe E, Blanquet M, Gerbaud L, Poirier G, Sass C, Vendittelli F, et al. A new reliable index to measure individual deprivation: the EPICES score. Eur J Public Health. 2015;25(4):604-9. Grolleau S, Delagrange M, Souquiere M, Molinas C, Diene G, Valette M, et al. Impact of Deprivation on Obesity in Children with PWS. J Clin Med. 2022;11(8). Borie AM, Dromard Y, Guillon G, Olma A, Manning M, Muscatelli F, et al. Correction of vasopressin deficit in the lateral septum ameliorates social deficits of mouse autism model. J Clin Invest. 2021;131(2). Damen L, Grootjen LN, Juriaans AF, Donze SH, Huisman TM, Visser JA, et al. Oxytocin in young children with Prader-Willi syndrome: Results of a randomized, double-blind, placebo-controlled, crossover trial investigating 3 months of oxytocin. Clin Endocrinol (Oxf). 2021;94(5):774-85. Dykens EM, Maxwell MA, Pantino E, Kossler R, Roof E. Assessment of hyperphagia in Prader-Willi syndrome. Obesity (Silver Spring). 2007;15(7):1816-26. Tauber M, Coupaye M, Diene G, Molinas C, Valette M, Beauloye V. Prader-Willi syndrome: A model for understanding the ghrelin system. J Neuroendocrinol. 2019;31(7):e12728. Collden G, Caron E, Bouret SG. Neonatal leptin antagonism improves metabolic programming of postnatally overnourished mice. Int J Obes (Lond). 2022;46(6):1138-44. Sedky K, Bennett DS, Pumariega A. Prader Willi syndrome and obstructive sleep apnea: co-occurrence in the pediatric population. J Clin Sleep Med. 2014;10(4):403-9. Jain V, Marbach J, Kimbro S, Andrade DC, Jain A, Capozzi E, et al. Benefits of oxytocin administration in obstructive sleep apnea. Am J Physiol Lung Cell Mol Physiol. 2017;313(5):L825-L33. Jain V, Kimbro S, Kowalik G, Milojevic I, Maritza Dowling N, Hunley AL, et al. Intranasal oxytocin increases respiratory rate and reduces obstructive event duration and oxygen desaturation in obstructive sleep apnea patients: a randomized double blinded placebo controlled study. Sleep Med. 2020;74:242-7. Harvey AR. Links Between the Neurobiology of Oxytocin and Human Musicality. Front Hum Neurosci. 2020;14:350. Mottolese R, Redoute J, Costes N, Le Bars D, Sirigu A. Switching brain serotonin with oxytocin. Proc Natl Acad Sci U S A. 2014;111(23):8637-42. Althammer F, Muscatelli F, Grinevich V, Schaaf CP. Oxytocin-based therapies for treatment of Prader-Willi and Schaaf-Yang syndromes: evidence, disappointments, and future research strategies. Transl Psychiatry. 2022;12(1):318. Supplementary Files SupplementarydataVF.docx Cite Share Download PDF Status: Published Journal Publication published 01 Mar, 2025 Read the published version in Orphanet Journal of Rare Diseases → Version 1 posted Editorial decision: Minor revision 11 Oct, 2024 Reviewers agreed at journal 05 Jul, 2024 Reviewers invited by journal 24 Jun, 2024 Editor assigned by journal 24 Jun, 2024 First submitted to journal 21 Jun, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4611289","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":318237223,"identity":"5506d960-cc9e-45cd-baba-a41dbaf9f995","order_by":0,"name":"Marion VALETTE","email":"","orcid":"","institution":"CHU Toulouse: Centre Hospitalier Universitaire de Toulouse","correspondingAuthor":false,"prefix":"","firstName":"Marion","middleName":"","lastName":"VALETTE","suffix":""},{"id":318237224,"identity":"20e3b045-cd2d-49dc-b70d-5a1236588ee2","order_by":1,"name":"Gwenaelle DIENE","email":"","orcid":"","institution":"CHU Toulouse: Centre Hospitalier Universitaire de Toulouse","correspondingAuthor":false,"prefix":"","firstName":"Gwenaelle","middleName":"","lastName":"DIENE","suffix":""},{"id":318237225,"identity":"79c6a93f-e84b-4a9a-83bb-0b63c3acab60","order_by":2,"name":"Mélanie GLATTARD","email":"","orcid":"","institution":"CHU Toulouse: Centre Hospitalier Universitaire de Toulouse","correspondingAuthor":false,"prefix":"","firstName":"Mélanie","middleName":"","lastName":"GLATTARD","suffix":""},{"id":318237226,"identity":"d447d84c-2e60-4784-8278-a6b9f202a1ed","order_by":3,"name":"Julie CORTADELLAS","email":"","orcid":"","institution":"CHU Toulouse: Centre Hospitalier Universitaire de Toulouse","correspondingAuthor":false,"prefix":"","firstName":"Julie","middleName":"","lastName":"CORTADELLAS","suffix":""},{"id":318237227,"identity":"22401138-8bf0-4d01-8c28-dbacbace1080","order_by":4,"name":"Catherine MOLINAS","email":"","orcid":"","institution":"CHU Toulouse: Centre Hospitalier Universitaire de 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11:02:33","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4611289/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4611289/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13023-025-03560-3","type":"published","date":"2025-03-01T15:57:50+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":60624414,"identity":"515fc574-94cd-4ec0-9660-9a920dede0c8","added_by":"auto","created_at":"2024-07-18 22:14:14","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":657651,"visible":true,"origin":"","legend":"\u003cp\u003eVABS II total scores and subscores of communication and socialization domains.\u003c/p\u003e\n\u003cp\u003eVABS total scores and subscores of communication (A and B) and socialization (C and D) in OT-exposed (gray) and non-exposed (white) groups. Horizontal dotted lines represent the thresholds above which scores were considered as low, moderately low and adequate scores.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4611289/v1/b9f80f6bcc09e4b19b870ff9.jpg"},{"id":60624410,"identity":"214a7d23-aea9-4643-b3f9-4ab2fb25a663","added_by":"auto","created_at":"2024-07-18 22:14:14","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1119307,"visible":true,"origin":"","legend":"\u003cp\u003eCBCL sub-scores in the OT-exposed and non-exposed groups according to genetic subtype groups (deletion \u003cem\u003evs.\u003c/em\u003e non-deletion). This figure shows the forest plot comparing the difference between the two genetic subtype groups (deletion \u003cem\u003evs.\u003c/em\u003e non-deletion) within the OT-exposed and non-exposed groups for each subscore. In the deletion subtype groups, there were significant differences or trends between the OT-exposed group and the non-exposed group in sub-scores adjusted on age.\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4611289/v1/94bce7939665582d712c78a9.jpg"},{"id":60624413,"identity":"a740c377-a983-4362-a651-58dfd1302ff1","added_by":"auto","created_at":"2024-07-18 22:14:14","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":424859,"visible":true,"origin":"","legend":"\u003cp\u003eCirculating AG (A), UAG (B) and AG/UAG ratio (C) levels in OT-exposed (gray box) and non-exposed (white box) PWS children and age-matched healthy controls (dotted box). The healthy control group comprises 29 children, mean age 3.5 years, from a previous study (12).\u003c/p\u003e","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4611289/v1/9bc0bc288d2f8db01fec54c5.jpg"},{"id":60625171,"identity":"8ce82752-e664-414d-99e9-c65d18e925b2","added_by":"auto","created_at":"2024-07-18 22:22:21","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":1485326,"visible":true,"origin":"","legend":"\u003cp\u003eBrain connectivity studies in fMRI in the OT-exposed and non-exposed groups.\u003c/p\u003e\n\u003cp\u003eBrain region connectivity in Orbito-frontal network (A and B) and Default Mode Network (DMN) (C and D) are shown. High connectivity regions in each network are shown in red (A and C). B and D showed higher connectivity Z-score in the OT-exposed children compared to non-exposed children in red (B) and in yellow (D); Correlations between connectivity Z-score of parahippocampus and VABSII socialization score (E). Correlations between connectivity Z-score of frontal cortex and UAG level in DMN (F).\u003c/p\u003e","description":"","filename":"Figure4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4611289/v1/863a4d548684625405103093.jpg"},{"id":77622685,"identity":"7a39314e-6c99-40d2-92d3-0f976569787b","added_by":"auto","created_at":"2025-03-03 16:09:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4508898,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4611289/v1/9cc1c75a-296b-4f6d-bafd-7a2635fc8c2d.pdf"},{"id":60624412,"identity":"c7d22cc1-5cc1-4be6-9b07-4b16fd5bb624","added_by":"auto","created_at":"2024-07-18 22:14:14","extension":"docx","order_by":9,"title":"","display":"","copyAsset":false,"role":"supplement","size":121688,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementarydataVF.docx","url":"https://assets-eu.researchsquare.com/files/rs-4611289/v1/223de7ba89e527a54a3b72f4.docx"}],"financialInterests":"","formattedTitle":"Early oxytocin treatment in infants with Prader-Willi is safe and is associated with better endocrine metabolic and behavior outcomes.","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eOxytocin (OT) plays an important role in modulating social interactions, mother-infant bonding and feeding. A reduced number and volume of OT neurons in the paraventricular nucleus were reported in postmortem human hypothalamic tissue from patients with Prader-Willi syndrome (PWS) (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). It is now acknowledged that the PWS phenotype is explained by impaired hypothalamic development and function including OT and ghrelin systems (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). PWS is clinically characterized by a specific developmental trajectory involving neurodevelopmental, nutritional, endocrine and metabolic, and behavioral dimensions (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). PWS results from the loss of expression of paternally inherited imprinted genes of chromosome 15 at position q11- q13 due to a paternal microdeletion, a maternal uniparental disomy (mUPD), an imprinting defect or a translocation involving this region (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Nowadays around 50% of the newborns display a microdeletion. The non-deletion genotype subtype comprises newborns with mUPD (around 45%) and imprinting defect (around 5%).\u003c/p\u003e \u003cp\u003eOur previous phase 2 study OTBB2 (NCT 02205034) showed that 16/18 infants with PWS younger than 6 months who received a short course of intranasal OT for 7 days improved their oral and social skills including mother-infant interactions after the last OT administration (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Circulating acylated ghrelin (AG) levels and the connectivity of the right superior orbitofrontal network were significantly increased (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). These results reproduced the preclinical data in \u003cem\u003eMagel2\u003c/em\u003e knock out (KO) mice, a mouse model obtained after inactivating \u003cem\u003eMagel2\u003c/em\u003e gene, one maternally imprinted gene of the PWS chromosomal region, showing that a single OT injection before the first 5 hours of life rescued 100% of the \u003cem\u003eMagel2\u003c/em\u003e KO pups from early death by restoring normal sucking activity (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). These rescued pups displayed normal socialization and increased memory and learning skills as adults (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn the current clinical trial, we want to evaluate the long-term tolerance and effects of 7 days of intranasal OT treatment in infants (\u0026lt;\u0026thinsp;6 months of age) who participated to the OTBB2 study by comparing them at 3 to 4 years of age to a group of age-matched children with PWS not treated with OT. This study aims to document for the first time in human long-term tolerance of early OT treatment and if it changes the course of the disease up to 4 years.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSTUDY POPULATION\u003c/h2\u003e \u003cp\u003eA detailed description of the population is shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Thirty-four children, 47% of female and 41% with deletion genetic subtype were included in this comparative study. Children belonged to one of the two groups, OT-exposed and non-exposed (17 children per group). These two groups were not statistical different regarding birth data, social status, family composition and schooling. In the whole group, median age was 3.8 years [3.0;4.3], BMI-Z-score was 0.08 [-1.79;6.31]. All children received GH treatment. All children were followed in dedicated PWS centers except for one OT-exposed child due to extreme poverty of the family with high social deprivation score.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of the population.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOT-exposed\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;17)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNon-exposed\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;17)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAll\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;34)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (yrs)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.8 (3.1;4.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.8 (3.0;4.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.8 (3.0;4.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex Female n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (41%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (53%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 (47%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eGenetics\u003c/span\u003e\u003c/p\u003e \u003cp\u003eDeletion n (%)\u003c/p\u003e \u003cp\u003eNon-deletion n (%)\u003c/p\u003e \u003cp\u003e- mUPD n (%)\u003c/p\u003e \u003cp\u003e- Imprinting defect n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (35%)\u003c/p\u003e \u003cp\u003e11 (65%)\u003c/p\u003e \u003cp\u003e9 (53%)\u003c/p\u003e \u003cp\u003e2 (12%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (47%)\u003c/p\u003e \u003cp\u003e9 (53%)\u003c/p\u003e \u003cp\u003e9 (53%)\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (41%)\u003c/p\u003e \u003cp\u003e20 (59%)\u003c/p\u003e \u003cp\u003e18 (53%)\u003c/p\u003e \u003cp\u003e2 (6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eAuxological data - body composition\u003c/span\u003e\u003c/p\u003e \u003cp\u003eWeight (kg)\u003c/p\u003e \u003cp\u003eWeight (DS)\u003c/p\u003e \u003cp\u003eHeight\u0026nbsp;(cm)\u003c/p\u003e \u003cp\u003eHeight (DS)\u003c/p\u003e \u003cp\u003eBMI kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eBMI (Z-score)\u003c/p\u003e \u003cp\u003eBMI Z-score\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;2\u003c/p\u003e \u003cp\u003eHead circumference (cm)\u003c/p\u003e \u003cp\u003eHead circumference (SDS)\u003c/p\u003e \u003cp\u003eBody fat mass (%)\u003c/p\u003e \u003cp\u003eBody lean mass (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15.4 (12.2;28.4)\u003c/p\u003e \u003cp\u003e0.7 (-1;10,7)\u003c/p\u003e \u003cp\u003e98.5 (92.5;108)\u003c/p\u003e \u003cp\u003e0.8 (-1.2;3.9)\u003c/p\u003e \u003cp\u003e15.9 (14.1;26.3)\u003c/p\u003e \u003cp\u003e0.13 (-1.5;6.31)\u003c/p\u003e \u003cp\u003e2 (12%)\u003c/p\u003e \u003cp\u003e49 (46.5;53) (n\u0026thinsp;=\u0026thinsp;16)\u003c/p\u003e \u003cp\u003e-0.35 (-2.5;2.7) (n\u0026thinsp;=\u0026thinsp;16)\u003c/p\u003e \u003cp\u003e22 (10;65) (n\u0026thinsp;=\u0026thinsp;17)\u003c/p\u003e \u003cp\u003e75 (32;85) (n\u0026thinsp;=\u0026thinsp;17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.6 (13;19.6)\u003c/p\u003e \u003cp\u003e0.6 (-1.1;4.8)\u003c/p\u003e \u003cp\u003e96 (90.5;107)\u003c/p\u003e \u003cp\u003e0.5 (-1.4;4.3)\u003c/p\u003e \u003cp\u003e15.4 (13.8;21.7)\u003c/p\u003e \u003cp\u003e-0.35 (-1.79;4.23)\u003c/p\u003e \u003cp\u003e2 (12%)\u003c/p\u003e \u003cp\u003e50 (48;52.5) (n\u0026thinsp;=\u0026thinsp;17)\u003c/p\u003e \u003cp\u003e-0.31 (-1.9;1.25) (n\u0026thinsp;=\u0026thinsp;17)\u003c/p\u003e \u003cp\u003e24.5 (8;40) (n\u0026thinsp;=\u0026thinsp;16)\u003c/p\u003e \u003cp\u003e71 (57;88) (n\u0026thinsp;=\u0026thinsp;16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15.2 (12.2;28.4)\u003c/p\u003e \u003cp\u003e0.6 (-1.1;10.7)\u003c/p\u003e \u003cp\u003e97.9 (90.5;108)\u003c/p\u003e \u003cp\u003e0.6 (-1.4;4.3)\u003c/p\u003e \u003cp\u003e15.8 (13.8;26.3)\u003c/p\u003e \u003cp\u003e0.08 (-1.79;6.31)\u003c/p\u003e \u003cp\u003e4 (12%)\u003c/p\u003e \u003cp\u003e50 (46.5;53) (n\u0026thinsp;=\u0026thinsp;33)\u003c/p\u003e \u003cp\u003e-0.31 (-2.5;2.7) (n\u0026thinsp;=\u0026thinsp;33)\u003c/p\u003e \u003cp\u003e22 (8;65) (n\u0026thinsp;=\u0026thinsp;33)\u003c/p\u003e \u003cp\u003e73 (32;88) (n\u0026thinsp;=\u0026thinsp;33)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eGH treatment\u003c/span\u003e\u003c/p\u003e \u003cp\u003e% of treated\u003c/p\u003e \u003cp\u003eDose at start GH treatment (\u0026micro;g/kg/day)\u003c/p\u003e \u003cp\u003eCurrent GH dose (\u0026micro;g/kg/day)\u003c/p\u003e \u003cp\u003eAge at start GH treatment (months)\u003c/p\u003e \u003cp\u003e% with at least 2 years of treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100%\u003c/p\u003e \u003cp\u003e26 (15;41)\u003c/p\u003e \u003cp\u003e27.6 (15.2;41.4)\u003c/p\u003e \u003cp\u003e10.0 (7.2;12.4)\u003c/p\u003e \u003cp\u003e100%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100%\u003c/p\u003e \u003cp\u003e25 (8;52)\u003c/p\u003e \u003cp\u003e28.6 (6.8;51.5)\u003c/p\u003e \u003cp\u003e13.2 (7.5;30.3)\u003c/p\u003e \u003cp\u003e94%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100%\u003c/p\u003e \u003cp\u003e26 (8;52)\u003c/p\u003e \u003cp\u003e28.1 (6.8;51.5)\u003c/p\u003e \u003cp\u003e10.6 (7.2\u0026ndash;30.3)\u003c/p\u003e \u003cp\u003e97%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003ePsychosocial and family data\u003c/span\u003e\u003c/p\u003e \u003cp\u003eNumber of siblings\u003c/p\u003e \u003cp\u003eCouple n (%)\u003c/p\u003e \u003cp\u003eSchooling n (%)\u003c/p\u003e \u003cp\u003eSocial vulnerability score (EPICES)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0;2)\u003c/p\u003e \u003cp\u003e12 (71%)\u003c/p\u003e \u003cp\u003e12 (71%)\u003c/p\u003e \u003cp\u003e16.6 (0;100) (n\u0026thinsp;=\u0026thinsp;17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (0;3)\u003c/p\u003e \u003cp\u003e14 (82%)\u003c/p\u003e \u003cp\u003e14 (82%)\u003c/p\u003e \u003cp\u003e16.9 (0;73) (n\u0026thinsp;=\u0026thinsp;16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (0;3)\u003c/p\u003e \u003cp\u003e26 (77%)\u003c/p\u003e \u003cp\u003e26 (77%)\u003c/p\u003e \u003cp\u003e16.6 (0;100) (n\u0026thinsp;=\u0026thinsp;33)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eBirth data\u003c/span\u003e\u003c/p\u003e \u003cp\u003eTerm (WA)\u003c/p\u003e \u003cp\u003ePremature birth n (%)\u003c/p\u003e \u003cp\u003eCesarean delivery n (%)\u003c/p\u003e \u003cp\u003eWeight (SDS)\u003c/p\u003e \u003cp\u003eLength (SDS)\u003c/p\u003e \u003cp\u003eNasogastric tube feeding (NGT) n (%)\u003c/p\u003e \u003cp\u003eDuration of NGT (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39 (30\u0026ndash;41)\u003c/p\u003e \u003cp\u003e3 (18%)\u003c/p\u003e \u003cp\u003e9 (53%) (n\u0026thinsp;=\u0026thinsp;17)\u003c/p\u003e \u003cp\u003e-1.7 (-2.9;-0.3) (n\u0026thinsp;=\u0026thinsp;17)\u003c/p\u003e \u003cp\u003e-0.9 (-2.5;0) (n\u0026thinsp;=\u0026thinsp;17)\u003c/p\u003e \u003cp\u003e15 (88%)\u003c/p\u003e \u003cp\u003e120 (14\u0026ndash;195)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39 (32\u0026ndash;41)\u003c/p\u003e \u003cp\u003e3 (18%)\u003c/p\u003e \u003cp\u003e10 (59%) (n\u0026thinsp;=\u0026thinsp;16)\u003c/p\u003e \u003cp\u003e-1.7(-2.3;0) (n\u0026thinsp;=\u0026thinsp;16)\u003c/p\u003e \u003cp\u003e-1.0 (-2.6;0) n\u0026thinsp;=\u0026thinsp;16)\u003c/p\u003e \u003cp\u003e13 (76%)\u003c/p\u003e \u003cp\u003e31 (2-210)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39 (30;41)\u003c/p\u003e \u003cp\u003e6 (18%)\u003c/p\u003e \u003cp\u003e19 (56%) (n\u0026thinsp;=\u0026thinsp;33)\u003c/p\u003e \u003cp\u003e-1.7 (-2.3;0) (n\u0026thinsp;=\u0026thinsp;33)\u003c/p\u003e \u003cp\u003e-0.9 (-2.6;0) (n\u0026thinsp;=\u0026thinsp;33)\u003c/p\u003e \u003cp\u003e28 (82%)\u003c/p\u003e \u003cp\u003e85 (2-210)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eResults are presented as n (%) or median (min-max) by groups and in all children. There was no statistical difference between the two groups regarding all the parameters of the table.\u003c/p\u003e \u003cp\u003e*The maximum score is 100, the cutoff of 30 was used to define social deprivation.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eSTUDY PROTOCOL\u003c/h2\u003e \u003cp\u003eThis single-center clinical trial compared the adaptive functioning, behavior and development, as well as feeding and social skills, endocrine, metabolic and safety issues, of 3- to 4-year-old PWS children who composed the 2 groups mentioned above. The OT-exposed group comprises 17 children who participated as infants in the OTBB2 study. The OTBB2 study was an open-label phase I/II escalating dose study with three groups of six infants with PWS, each group receiving the same dose which increased from group 1 to group 3 as described: OT 4 IU every other day, every day, twice a day for a total duration of treatment of 7 days. Children of the non-exposed group were aged-matched (with a maximum difference of plus or minus 3 months) with children of the OT-exposed. All children were admitted for a single 3-day visit in the Hospital hosting the French reference center for PWS in Toulouse. The complete study protocol is available at \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.chu-toulouse.fr/IMG/pdf/final_protocole__ot2suite_v1.6_22032017-en.pdf\u003c/span\u003e\u003cspan address=\"https://www.chu-toulouse.fr/IMG/pdf/final_protocole__ot2suite_v1.6_22032017-en.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e and details of inclusion and exclusion criteria are detailed below.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eInclusion/Exclusion criteria\u003c/h2\u003e \u003cp\u003eAmong the 18 patients included in the OTBB2 study, one was lost to follow-up; the 17 remaining patients were included in this current study. One patient combining severe social economic deprivation regarding the EPICES score (\u0026gt;\u0026thinsp;50) and poverty, defined as extreme deprived conditions of life confirmed by the clinical team, was excluded of the Vineland socialization domain analysis because both conditions have a severe impact on care, social adaptive skills and behavior.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eOutcomes and data collected\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eAdaptive functioning\u003c/span\u003e: the primary endpoint was the score in the communication domain of the Vineland adaptive behavior scale version II (VABS-II) (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). The VABS-II evaluates adaptive functioning in four domains: Communication, Socialization, Daily Living Skills and Motor Skills expressed in scores and categorized in adequate /moderately low /low. Age equivalent scores and standard scores (mean (M)\u0026thinsp;=\u0026thinsp;100; standard deviation (SD)\u0026thinsp;=\u0026thinsp;15) are provided for each domain. The other subscores of the VABS-II were analyzed as secondary endpoints as were the following evaluations.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eBehavior\u003c/span\u003e: behavior was assessed with the Child Behavior Check List (CBCL) using its total T score and 14 subscores (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eFeeding skills\u003c/span\u003e: a dynamic videofluoroscopy of swallowing (VFSS) was performed and scored with a chart including the analysis of the five phases of swallowing. Eating behavior was assessed by a questionnaire used in routine care in our center. It was completed by the pediatrician during an interview with the parents, with 5-point Likert scale responses (Supplementary Table\u0026nbsp;1).\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eGrowth and development\u003c/span\u003e: children were measured and weighed during the study visit. Development was assessed by the Bayley Scale of Infant and Toddler Development version III (BSID-III), which included cognitive, receptive language, expressive language, fine motor, and gross motor scores (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eEndocrine and metabolic evaluations\u003c/span\u003e: sampling for hormone and metabolic assays: Measurements of IGF-1, thyroid hormones, glycaemia, insulin and lipids were performed as routine evaluations. Plasma concentrations of acylated ghrelin (AG), unacylated ghrelin (UAG) and OT were measured as previously described (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). We then compared the ghrelin data with data from age-matched healthy controls from our previous studies (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eBrain connectivity analysis during resting state using functional MRI (fMRI)\u003c/span\u003e: the children lay supine and were instructed to relax and keep their eyes closed, but not to sleep. fMRI preprocessing and statistical analyses are described in the supplementary methods. We chose to study the default mode network (DMN) which has frequently been studied and the orbitofrontal cortex network (superior, median and inferior) as in the OTBB2 study (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTo reveal the areas where significant connectivity change occurred, we set up the threshold for the Statistical Maps at p\u0026thinsp;\u0026lt;\u0026thinsp;0.005 voxel-wise and we used a threshold for cluster extent of P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 corrected for multiple comparisons across the whole brain.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eComorbidities\u003c/span\u003e: sleep disorders and orthopedic problems reported in children medical files were collected.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eEvaluation of tolerance\u003c/span\u003e: tolerance was assessed by recording vital signs, physical examination sign, laboratory parameters and adverse events (AE);\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eEvaluation of social deprivation\u003c/span\u003e: the EPICES score (Evaluation of the Deprivation and Inequalities of Health in Healthcare Centers) is a self -questionnaire validated in France (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) that evaluates the social deprivation of the family as defined by limited access to society\u0026rsquo;s resources due to poverty, discrimination, or other disadvantages. The score ranges from 0 to 100 with a threshold of \u0026gt;\u0026thinsp;30 defining social deprivation.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eComparisons between OT-exposed and non-exposed group were performed.\u003c/p\u003e \u003cp\u003eResults for all variables, including each item of the questionnaires, were summarized by group using descriptive statistics or frequency/percentage, as appropriate. A parametric approach (Student t-test) or a non-parametric approach (Mann-Whitney) according to the normality/non-normality distribution was used to compare groups. Subgroups statistical analysis was done using an analysis of variance (ANOVA). The model included group (treated vs. untreated) and age group (1st, 2nd, and 3rd terciles) as fixed effects.\u003c/p\u003e \u003cp\u003eSubgroup analysis was performed to explore the group effect within two levels of genetic diagnosis (deletion and non-deletion). When differences were found between the two genetics subtypes within OT-exposed vs non-exposed groups they were mentioned in the result section. Differences in the proportions of normal and abnormal patients, defined by thresholds, between the OT-exposed and non-exposed groups were analyzed using a Cochran-Mantel-Haenszel test with age group as the controlling factor.\u003c/p\u003e \u003cp\u003e Statistical analysis was performed using SAS\u0026reg; Enterprise Guide software, version 7.1 (SAS Institute, Cary, NC, US) and Stata version 11.2 (Stata Corp, College Station, TX). The statistical significance threshold was set at 0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eAdaptive behavior\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ePrimary endpoint: VABS-II\u003c/span\u003e \u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003ecommunication domain\u003c/span\u003e\u003c/p\u003e \u003cp\u003eThe mean total communication score (74 in OT-exposed \u003cem\u003evs.\u003c/em\u003e 75 in non-exposed) and subscores were not significantly different between the two groups (Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA and \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eSecondary endpoints\u003c/h2\u003e \u003cdiv id=\"Sec11\" class=\"Section3\"\u003e \u003ch2\u003eSocialization domain\u003c/h2\u003e \u003cp\u003eThis domain comprises three subscores: coping skills, interpersonal relationships and play leisure. We found a trend for higher mean total socialization score in the OT-exposed group excluding the child with social deprivation and extreme poverty (76 in OT-exposed \u003cem\u003evs\u003c/em\u003e. 70 in non-exposed, p\u0026thinsp;=\u0026thinsp;0.063) adjusted on age (Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eC and \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eD) compared to the non-exposed group. The total socialization score was adequate in 24% \u003cem\u003evs.\u003c/em\u003e 6% in the OT-exposed \u003cem\u003evs.\u003c/em\u003e non-exposed group, (p\u0026thinsp;=\u0026thinsp;0.098). In the non-deletion genetic subtype groups, the interpersonal relationships sub-score was adequate in 29% in the OT-exposed children vs none in the non-exposed children (p\u0026thinsp;=\u0026thinsp;0.020).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eOther domains of the VABS-II\u003c/h2\u003e \u003cp\u003eThe two other domains of the VABS-II (daily living skills and motor skills) were not significantly different between the OT-exposed and non-exposed groups using total scores or subscores.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eBehavior\u003c/h2\u003e \u003cp\u003eThe mean total score of the CBCL was not significantly different between the two groups when adjusted on age (52 in the OT-exposed \u003cem\u003evs.\u003c/em\u003e 55 in the non-exposed group, p\u0026thinsp;=\u0026thinsp;0.37). The internalizing problems subscore was normal in 94% vs. 65% (p\u0026thinsp;=\u0026thinsp;0.04) and the emotionally reactive subscore was normal in 94% vs. 71% (p\u0026thinsp;=\u0026thinsp;0.08) in the OT-exposed \u003cem\u003evs.\u003c/em\u003e the non-exposed group respectively. Figure\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the forest plot comparing the difference between the deletion vs. non-deletion genetic subtype groups within the OT-exposed and the non-exposed groups. In the deletion subtype group we found statistically significant differences or a trend in many subscores between the OT-exposed and non-exposed groups with better subscores in the OT-exposed children (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eOral skills\u003c/h2\u003e \u003cp\u003eThe total VFSS score was abnormal in all children. No statistically significant difference was observed between the OT-exposed and non-exposed groups for the mean total score or the distribution of children with normal and abnormal subscores, although there were trends for more normal subscores in the OT-exposed group (see Supplementary Table\u0026nbsp;2).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eFeeding behavior\u003c/h2\u003e \u003cp\u003eMean total score of the feeding behavior questionnaire was similar in the OT-exposed and non-exposed groups (11.6 vs 13.3, p\u0026thinsp;=\u0026thinsp;0.5). We found a significant difference only for question 13, in the non-deletion genetic subtype groups (interaction treatment*genotype, p\u0026thinsp;=\u0026thinsp;0.02) with 55% of the non-exposed children requiring food access control vs no children in the OT-exposed group.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eDevelopment\u003c/h2\u003e \u003cp\u003eThe BSID-III scores were not different between the two groups. Most of the children were classified as abnormal (see Supplementary Fig.\u0026nbsp;1).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eComorbidities\u003c/h2\u003e \u003cp\u003eComorbidities are listed in Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eEndocrine and metabolic disorders\u003c/span\u003e: all children received GH treatment at the same recommended dose and median IGF-1 levels were in the normal range with significantly higher values in the OT-exposed group compared to the non-exposed group (198 ng/mL \u003cem\u003evs.\u003c/em\u003e 132 ng/mL, p\u0026thinsp;=\u0026thinsp;0.01). Median HDL-cholesterol levels were significantly higher in the OT-exposed group compared to the non-exposed group (0.52 g/L \u003cem\u003evs\u003c/em\u003e. 0.46 g/L, p\u0026thinsp;=\u0026thinsp;0.02). There was a trend for higher T4L in the OT-exposed group which was related to the higher frequency of L-Thyroxine treatment in this group.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComorbidities presented by the children in each group and comparison between groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOT-exposed (N\u0026thinsp;=\u0026thinsp;17)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNon-exposed (N\u0026thinsp;=\u0026thinsp;17)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEndocrine and metabolic comorbidities\u003c/b\u003e\u003c/p\u003e \u003cp\u003eIGF-1(ng/mL)\u003c/p\u003e \u003cp\u003eFree Thyroxine (ng/L)\u003c/p\u003e \u003cp\u003eTreatment by L-Thyroxin n (%)\u003c/p\u003e \u003cp\u003eDosing (\u0026micro;g/d)\u003c/p\u003e \u003cp\u003eHDL Cholesterol (g/L)**\u003c/p\u003e \u003cp\u003eLDL Cholesterol (g/L)\u003c/p\u003e \u003cp\u003eVLDL Cholesterol (g/L)\u003c/p\u003e \u003cp\u003eTotal Cholesterol (g/L)\u003c/p\u003e \u003cp\u003eTriglycerides (g/L)\u003c/p\u003e \u003cp\u003eGlycemia (g/L)\u003c/p\u003e \u003cp\u003eInsulinemia (mIU/L)\u003c/p\u003e \u003cp\u003eHOMA-IR (min-max)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e198 (36\u0026ndash;267)\u003c/b\u003e\u003c/p\u003e \u003cp\u003e13.2 (10.4\u0026ndash;15)\u003c/p\u003e \u003cp\u003e10 (59%)\u003c/p\u003e \u003cp\u003e17.5 (10\u0026ndash;50)\u003c/p\u003e \u003cp\u003e\u003cb\u003e0.52 (0.38\u0026ndash;0.82)\u003c/b\u003e\u003c/p\u003e \u003cp\u003e1.05 (0.67\u0026ndash;1.95)\u003c/p\u003e \u003cp\u003e0.15 (0.08\u0026ndash;0.22)\u003c/p\u003e \u003cp\u003e1.71 (1.27\u0026ndash;2.59)\u003c/p\u003e \u003cp\u003e0.73 (0.39\u0026ndash;1.12)\u003c/p\u003e \u003cp\u003e0.76 (0.6\u0026ndash;1.08)\u003c/p\u003e \u003cp\u003e5.1 (1.9\u0026ndash;18.3) (N\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e \u003cp\u003e0.9 (0.4\u0026ndash;4.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e132(26\u0026ndash;266)\u003c/b\u003e\u003csup\u003e\u003cb\u003e\u0026pound;\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e12.2 (9.5\u0026ndash;15.3)\u003c/p\u003e \u003cp\u003e5 (29%)\u003c/p\u003e \u003cp\u003e20 (\u003cspan additionalcitationids=\"CR11 CR12 CR13 CR14 CR15 CR16 CR17 CR18 CR19 CR20 CR21 CR22 CR23 CR24\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e\u003cb\u003e0.46 (0.33\u0026ndash;0.6)\u003c/b\u003e\u003c/p\u003e \u003cp\u003e1 (0.36\u0026ndash;1.8)\u003c/p\u003e \u003cp\u003e0.14 (0.1\u0026ndash;0.28)\u003c/p\u003e \u003cp\u003e1.61 (1.02\u0026ndash;3.48)\u003c/p\u003e \u003cp\u003e0.7 (0.5\u0026ndash;1.4)\u003c/p\u003e \u003cp\u003e0.74 (0.52\u0026ndash;0.9)\u003c/p\u003e \u003cp\u003e4.8 (1.9\u0026ndash;12.2) (N\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e \u003cp\u003e1 (0.3\u0026ndash;2.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.01\u003c/b\u003e\u003c/p\u003e \u003cp\u003e0.07\u003c/p\u003e \u003cp\u003eNS\u003c/p\u003e \u003cp\u003eNS\u003c/p\u003e \u003cp\u003e\u003cb\u003e0.02\u003c/b\u003e\u003c/p\u003e \u003cp\u003eNS\u003c/p\u003e \u003cp\u003eNS\u003c/p\u003e \u003cp\u003eNS\u003c/p\u003e \u003cp\u003eNS\u003c/p\u003e \u003cp\u003eNS\u003c/p\u003e \u003cp\u003eNS\u003c/p\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSleep respiratory disorders\u003c/b\u003e (polysomnography before GH)\u003c/p\u003e \u003cp\u003eApnea hypopnea index (AHI)\u003c/p\u003e \u003cp\u003eObstructive apnea index (OAI)\u003c/p\u003e \u003cp\u003eCentral apnea index (CAI)*\u003c/p\u003e \u003cp\u003e% of children with ICA\u0026thinsp;\u0026ge;\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;13\u003c/p\u003e \u003cp\u003e2.9 (0.5;15.5)\u003c/p\u003e \u003cp\u003e0 (0;9.9)\u003c/p\u003e \u003cp\u003e0.5 (0;4.4) (N\u0026thinsp;=\u0026thinsp;13)\u003c/p\u003e \u003cp\u003e\u003cb\u003e46%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;12\u003c/p\u003e \u003cp\u003e3.5 (0;56.8)\u003c/p\u003e \u003cp\u003e0 (0;2.3)\u003c/p\u003e \u003cp\u003e2.3 (0\u0026nbsp;;18.7) (N\u0026thinsp;=\u0026thinsp;12)\u003c/p\u003e \u003cp\u003e\u003cb\u003e83%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003cp\u003eNS\u003c/p\u003e \u003cp\u003e0.06\u003c/p\u003e \u003cp\u003e\u003cb\u003e0.03\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eScoliosis\u003c/b\u003e n (%)\u003c/p\u003e \u003cp\u003eAge at diagnosis (yrs)\u003c/p\u003e \u003cp\u003eCobb angle (\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (35%)\u003c/p\u003e \u003cp\u003e1.75 (1.05\u0026ndash;2.11)\u003c/p\u003e \u003cp\u003e30 (15\u0026ndash;56) (N\u0026thinsp;=\u0026thinsp;5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (29%)\u003c/p\u003e \u003cp\u003e1.69 (1.09\u0026ndash;2.19)\u003c/p\u003e \u003cp\u003e29 (17\u0026ndash;80) (N\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eResults are presented as n (%) or median (min-max) by groups and in all children \u003csup\u003e\u0026pound;\u003c/sup\u003e n\u0026thinsp;=\u0026thinsp;16\u003c/p\u003e \u003cp\u003e*logistical regression adjusted for age.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eGhrelin levels:\u003c/h2\u003e \u003cp\u003eThe OT-exposed group showed a trend for lower AG levels \u003cem\u003evs.\u003c/em\u003e the non-exposed group (172 ng/mL \u003cem\u003evs.\u003c/em\u003e 257 ng/mL, p\u0026thinsp;=\u0026thinsp;0.06) with no significant difference in UAG and a trend for a lower AG/UAG ratio (1.37 \u003cem\u003evs.\u003c/em\u003e 1.91, p\u0026thinsp;=\u0026thinsp;0.09) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). When compared to a healthy control group of same age range, the OT-exposed group had similar AG levels (172 ng/mL in OT-exposed group \u003cem\u003evs.\u003c/em\u003e 115 ng/mL in healthy controls) whereas UAG was significantly higher (130 ng/mL \u003cem\u003evs.\u003c/em\u003e 76 ng/mL, p\u0026thinsp;=\u0026thinsp;0.007) with no difference in the AG/UAG ratio. The non-exposed group had significantly higher levels of both AG (257 ng/mL \u003cem\u003evs.\u003c/em\u003e 115 ng/mL, p\u0026thinsp;=\u0026thinsp;0.03) and UAG (127 ng/mL \u003cem\u003evs.\u003c/em\u003e 76 ng/mL, p\u0026thinsp;=\u0026thinsp;0.005) compared to the healthy control group adjusted for age with no difference in the AG/UAG ratio.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eSleep disorders\u003c/span\u003e: patients underwent polysomnography before the start of GH treatment at a median age of 8.5 months (range 5.1\u0026ndash;10.7 months) in the OT-exposed group (N\u0026thinsp;=\u0026thinsp;13) \u003cem\u003evs.\u003c/em\u003e 12.6 months (range 7.3 to 26) in the non-exposed group (N\u0026thinsp;=\u0026thinsp;12). Forty-six percent of OT-exposed children had central apnea (central apnea index (CAI)\u0026thinsp;\u0026gt;\u0026thinsp;1) before initiating GH treatment \u003cem\u003evs.\u003c/em\u003e 83% of the non-exposed children (p\u0026thinsp;=\u0026thinsp;0.03). We found a trend towards a lower median CAI adjusted on age in the OT-exposed group \u003cem\u003evs.\u003c/em\u003e the non-exposed group (0.5 \u003cem\u003evs.\u003c/em\u003e 2.3/hr respectively, p\u0026thinsp;=\u0026thinsp;0.06). No difference was observed after GH treatment.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eScoliosis\u003c/span\u003e: no difference was observed regarding the occurrence of scoliosis: 35% in the OT-exposed group \u003cem\u003evs\u003c/em\u003e. 29% in the non-exposed group.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eSafety\u003c/h2\u003e \u003cp\u003eOverall, three subjects in the OT-exposed group (17.6%) and seven subjects in the non-exposed group (41.2%) reported at least one adverse event during the study (see Supplementary Table\u0026nbsp;3), none of them related to the intranasal OT treatment.\u003c/p\u003e \u003cp\u003eComparison of body measures, vital signs, and standard laboratory parameters between the two groups OT-exposed and the non-exposed group, showed no evidence of any negative effect of OT treatment.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eCirculating OT levels\u003c/h2\u003e \u003cp\u003eNo difference in circulating OT levels was found between the two groups: 0.44 ng/L in the OT-exposed group \u003cem\u003evs.\u003c/em\u003e 0.45 ng/L in the non-exposed group.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eBrain fMRI\u003c/h2\u003e \u003cp\u003eAmong the 18 patients who underwent the fMRI, only 10 (6 in the OT-exposed group and 4 in the non-exposed group) were able to stay motionless during fMRI acquisition and completed the whole experiment. In the DMN analysis, the OT-exposed group showed higher connectivity of the right hippocampus, precuneus and the medial frontal cortex regions (p\u0026thinsp;\u0026lt;\u0026thinsp;0.005) (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eA \u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eC). In the orbitofrontal component analysis, the OT-exposed group showed a higher connectivity in the inferior occipital, precentral, medial frontal and cuneus regions (p\u0026thinsp;\u0026lt;\u0026thinsp;0.005) (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eB \u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eD). There was a negative correlation within the whole group between the VABS-II total score of socialization and the connectivity of the parahippocampus (p\u0026thinsp;=\u0026thinsp;0.036) (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eE) and a negative correlation with the circulating UAG level and the connectivity of the frontal cortex (p\u0026thinsp;=\u0026thinsp;0.022) shown in (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eF).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis clinical trial allowed us to document for the first time the good long-term tolerance of early OT treatment of infants with PWS who participated to the OTBB2 study(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) and to compare the characteristics and the severity of the disease in these children at 3 to 4 years with an age-matched non-exposed group of PWS children. We did not find a statistically significant difference between the two OT-exposed and non-exposed groups for adaptive skills of the communication domain using the VABS-II, which was the primary endpoint of our study. We found a strong signal regarding socialization domain, with a trend toward higher score and more children with adequate socialization scores in the OT-exposed group compared to the non-exposed group. This long-term effect of OT on social skills has been demonstrated in the \u003cem\u003eMagel2\u003c/em\u003e gene inactivated mouse model and is consistent with the known effect of OT in bonding and in setting the network for social recognition (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRegarding the comprehensive evaluation of behavior using the CBCL which is widely used in PWS, we did not find a significant difference between OT-exposed and non-exposed groups. Interestingly in the deletion genetic subtype groups we found better outcome in the OT-exposed vs non-exposed children in most of the subscores. The influence of genetic subtype on the effect of OT treatment was also reported in a 3 months study in children with PWS (age 3\u0026ndash;11 years) (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). This study showed significant improvement of Dykens Hyperphagia questionnaire (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) and global behavior score after OT treatment vs placebo only in the deletion group of children (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Conversely in our study the differences between the OT-exposed and non-exposed group regarding the need for control access for food was only observed in the non-deletion genetic subtype children. For the other endpoints, we did not find the influence of the genetic subtype. Oral skills analyzed by VFSS were not significantly different between the two groups but we observed a trend for more frequently adequate swallowing pharyngeal initiation and protection of respiratory airway in the OT-exposed group.\u003c/p\u003e \u003cp\u003eInterestingly we found significant differences between the two OT-exposed and non-exposed groups on endocrine and metabolic comorbidities. Although all children received GH treatment at the same dose, the OT-exposed group displayed significantly higher levels of IGF-1 suggesting greater GH sensitivity, which may be explained by better metabolic outcome as HDL-cholesterol levels were also significantly higher in the OT-exposed group. Hyperghrelinemia is a cardinal metabolic marker of PWS. As a group, patients with PWS display high AG and UAG levels at all ages (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). We previously showed normalization of AG levels in the OTBB2 trial (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) and we reported in this study that this effect persists up to 4 years of age. The results suggest that early OT treatment may prevent the switch in the ghrelin system observed in PWS (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). The significant differences observed in endocrine and metabolic trajectories are unexplained but are comparable with the results obtained by attenuating leptin effect during early life that improves lifelong metabolic regulation in postnatally overnourished mice (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCentral apnea is a common feature in infants and children with PWS (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Our study showed that the OT-exposed children displayed less frequently central apnea before the start of GH treatment than the non-exposed children, which suggests that early OT treatment may also prime the autonomic system linked with respiratory control. One study reported a positive effect of OT administration on sleep respiratory disorders in non-PWS adult obese patients and showed a reduction of the frequency of hypopneas and the duration of apneas and hypopneas (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe current study showed differences between the OT-exposed group and non-exposed group in the brain connectivity of regions involved in neurodevelopment which were identified in the OTBB2 study (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), thereby documenting a long-term effect of OT on brain plasticity particularly in regions involved in the regulation of socialization and feeding, such as the parahippocampus and the frontal cortex (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). As a whole, our study paves the way to demonstrate the long-term effects of early OT treatment during a post-natal critical period in humans (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Children of the OT-exposed group are now 9 to 10 years old. They are routinely followed in our center and we confirm excellent long-term tolerance of early OT treatment (data not shown).\u003c/p\u003e \u003cp\u003eWe recently completed a phase III European study comprising 52 PWS infants who received a longer course of OT treatment (1 or 2 months). These OT treated infants will be followed yearly until 4 years of age to confirm the good long-term tolerance and will be compared to non-exposed children in order to confirm our current data with a longer duration of early OT exposition of infants.\u003c/p\u003e \u003cp\u003eStrength and limitations of the study: although the study population was small due to the rarity of the disease, the evaluations including biological and endocrine aspects were performed in the same expert center with patients coming from the whole country.\u003c/p\u003e \u003cp\u003eIn conclusion, our comparative study demonstrated the long-term safety of early short course (7 days) of intranasal OT treatment in infants with PWS and better outcomes at 3 to 4 years regarding behavior, endocrine and metabolism, as well as differences in brain regions of interest connectivity. This study documents for the first time in human the postnatal critical period that offers a window of opportunity to implement OT treatment to change the trajectories of the disease.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cu\u003eEthics approval and consent to participate:\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe clinical study was approved by the Comité de Protection des Personnes Sud-Ouest et Outremer I.\u0026nbsp;Written informed consent was provided by the parents of the children.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eConsent for publication:\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eAll authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eAvailability of data and materials:\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available from CHU of Toulouse but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of CHU of Toulouse.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eCompeting interests:\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eFunding:\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eFunding was obtained from Prader-Willi France Association. The Start-up OT4B funded the statistical analysis made by the clinical research organization Atlanstat.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eAuthors' contributions:\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eDr Marion Valette, Prof Maithé Tauber, Dr Gwenaelle Diene, Mrs Catherine Molinas and Dr Catherine Arnaud conceptualized and designed the study, drafted the initial manuscript, and critically reviewed and revised the manuscript.\u003c/p\u003e\n\u003cp\u003eMrs Melanie Glattard, performed the Vineland study and drafted the initial manuscript and critically reviewed and revised the manuscript.\u003c/p\u003e\n\u003cp\u003eDr Sophie Çabal and Dr Gregoire Benvegnu drafted the initial manuscript, and critically reviewed and revised the manuscript.\u003c/p\u003e\n\u003cp\u003eMrs Julie Cortadellas and Dr Sandy Faye, designed the data collection instruments, collected data, and critically reviewed and revised the manuscript.\u003c/p\u003e\n\u003cp\u003eProf Jean Pierre Salles critically reviewed and revised the manuscript for important intellectual content.\u003c/p\u003e\n\u003cp\u003eDr Kader Boulanouar and Prof Pierre Payoux designed the brain MRI studies, wrote this part of the manuscript and reviewed the entire manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eAcknowledgements:\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eWe thank Cathy Brochado for collection of data and Camille Lassale for post-hoc statistical analyses.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSwaab DF, Purba JS, Hofman MA. Alterations in the hypothalamic paraventricular nucleus and its oxytocin neurons (putative satiety cells) in Prader-Willi syndrome: a study of five cases. J Clin Endocrinol Metab. 1995;80(2):573-9.\u003c/li\u003e\n\u003cli\u003eTauber M, Hoybye C. Endocrine disorders in Prader-Willi syndrome: a model to understand and treat hypothalamic dysfunction. Lancet Diabetes Endocrinol. 2021;9(4):235-46.\u003c/li\u003e\n\u003cli\u003eMiller JL, Lynn CH, Driscoll DC, Goldstone AP, Gold JA, Kimonis V, et al. Nutritional phases in Prader-Willi syndrome. Am J Med Genet A. 2011;155A(5):1040-9.\u003c/li\u003e\n\u003cli\u003eCassidy SB, Schwartz S, Miller JL, Driscoll DJ. Prader-Willi syndrome. Genet Med. 2012;14(1):10-26.\u003c/li\u003e\n\u003cli\u003eBuiting K, Cassidy SB, Driscoll DJ, Gillessen-Kaesbach G, Kanber D, Tauber M, et al. Clinical utility gene card for: Prader-Willi Syndrome. Eur J Hum Genet. 2014;22(9).\u003c/li\u003e\n\u003cli\u003eTauber M, Boulanouar K, Diene G, Cabal-Berthoumieu S, Ehlinger V, Fichaux-Bourin P, et al. The Use of Oxytocin to Improve Feeding and Social Skills in Infants With Prader-Willi Syndrome. Pediatrics. 2017;139(2).\u003c/li\u003e\n\u003cli\u003eSchaller F, Watrin F, Sturny R, Massacrier A, Szepetowski P, Muscatelli F. A single postnatal injection of oxytocin rescues the lethal feeding behaviour in mouse newborns deficient for the imprinted Magel2 gene. Hum Mol Genet. 2010;19(24):4895-905.\u003c/li\u003e\n\u003cli\u003eMeziane H, Schaller F, Bauer S, Villard C, Matarazzo V, Riet F, et al. An Early Postnatal Oxytocin Treatment Prevents Social and Learning Deficits in Adult Mice Deficient for Magel2, a Gene Involved in Prader-Willi Syndrome and Autism. Biol Psychiatry. 2015;78(2):85-94.\u003c/li\u003e\n\u003cli\u003eSparow SS, Cicchetti DV, Balla DA. Vineland-II, Echelles de comportement adaptatif de Vineland. 2nd edition ed2015.\u003c/li\u003e\n\u003cli\u003eAchenbach TM, Rescorla LA. Manual for the ASEBA School-Age Forms \u0026amp; Profiles: Burlington, VT: University of Vermont, Research Center for Children, Youth, \u0026amp; Families; 2001.\u003c/li\u003e\n\u003cli\u003eBayley N. Bayley Scales of Infant and Toddler Development. 3rd edition ed2006.\u003c/li\u003e\n\u003cli\u003eBeauloye V, Diene G, Kuppens R, Zech F, Winandy C, Molinas C, et al. High unacylated ghrelin levels support the concept of anorexia in infants with prader-willi syndrome. Orphanet J Rare Dis. 2016;11(1):56.\u003c/li\u003e\n\u003cli\u003eKuppens RJ, Diene G, Bakker NE, Molinas C, Faye S, Nicolino M, et al. Elevated ratio of acylated to unacylated ghrelin in children and young adults with Prader-Willi syndrome. Endocrine. 2015;50(3):633-42.\u003c/li\u003e\n\u003cli\u003eLabbe E, Blanquet M, Gerbaud L, Poirier G, Sass C, Vendittelli F, et al. A new reliable index to measure individual deprivation: the EPICES score. Eur J Public Health. 2015;25(4):604-9.\u003c/li\u003e\n\u003cli\u003eGrolleau S, Delagrange M, Souquiere M, Molinas C, Diene G, Valette M, et al. Impact of Deprivation on Obesity in Children with PWS. J Clin Med. 2022;11(8).\u003c/li\u003e\n\u003cli\u003eBorie AM, Dromard Y, Guillon G, Olma A, Manning M, Muscatelli F, et al. Correction of vasopressin deficit in the lateral septum ameliorates social deficits of mouse autism model. J Clin Invest. 2021;131(2).\u003c/li\u003e\n\u003cli\u003eDamen L, Grootjen LN, Juriaans AF, Donze SH, Huisman TM, Visser JA, et al. Oxytocin in young children with Prader-Willi syndrome: Results of a randomized, double-blind, placebo-controlled, crossover trial investigating 3 months of oxytocin. Clin Endocrinol (Oxf). 2021;94(5):774-85.\u003c/li\u003e\n\u003cli\u003eDykens EM, Maxwell MA, Pantino E, Kossler R, Roof E. Assessment of hyperphagia in Prader-Willi syndrome. Obesity (Silver Spring). 2007;15(7):1816-26.\u003c/li\u003e\n\u003cli\u003eTauber M, Coupaye M, Diene G, Molinas C, Valette M, Beauloye V. Prader-Willi syndrome: A model for understanding the ghrelin system. J Neuroendocrinol. 2019;31(7):e12728.\u003c/li\u003e\n\u003cli\u003eCollden G, Caron E, Bouret SG. Neonatal leptin antagonism improves metabolic programming of postnatally overnourished mice. Int J Obes (Lond). 2022;46(6):1138-44.\u003c/li\u003e\n\u003cli\u003eSedky K, Bennett DS, Pumariega A. Prader Willi syndrome and obstructive sleep apnea: co-occurrence in the pediatric population. J Clin Sleep Med. 2014;10(4):403-9.\u003c/li\u003e\n\u003cli\u003eJain V, Marbach J, Kimbro S, Andrade DC, Jain A, Capozzi E, et al. Benefits of oxytocin administration in obstructive sleep apnea. Am J Physiol Lung Cell Mol Physiol. 2017;313(5):L825-L33.\u003c/li\u003e\n\u003cli\u003eJain V, Kimbro S, Kowalik G, Milojevic I, Maritza Dowling N, Hunley AL, et al. Intranasal oxytocin increases respiratory rate and reduces obstructive event duration and oxygen desaturation in obstructive sleep apnea patients: a randomized double blinded placebo controlled study. Sleep Med. 2020;74:242-7.\u003c/li\u003e\n\u003cli\u003eHarvey AR. Links Between the Neurobiology of Oxytocin and Human Musicality. Front Hum Neurosci. 2020;14:350.\u003c/li\u003e\n\u003cli\u003eMottolese R, Redoute J, Costes N, Le Bars D, Sirigu A. Switching brain serotonin with oxytocin. Proc Natl Acad Sci U S A. 2014;111(23):8637-42.\u003c/li\u003e\n\u003cli\u003eAlthammer F, Muscatelli F, Grinevich V, Schaaf CP. Oxytocin-based therapies for treatment of Prader-Willi and Schaaf-Yang syndromes: evidence, disappointments, and future research strategies. Transl Psychiatry. 2022;12(1):318.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"orphanet-journal-of-rare-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ojrd","sideBox":"Learn more about [Orphanet Journal of Rare Diseases](http://ojrd.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ojrd/default.aspx","title":"Orphanet Journal of Rare Diseases","twitterHandle":"@bmc","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Prader-Willi syndrome, oxytocin, infants, long-term effects, behavior, metabolism, brain connectivity","lastPublishedDoi":"10.21203/rs.3.rs-4611289/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4611289/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Oxytocin (OT) plays an important role in modulating behavior social interactions and feeding. Prader-Willi syndrome (PWS), a rare genetic neurodevelopmental disorder, is a\u0026nbsp;model of hypothalamic disorder\u0026nbsp;including OT dysfunction. We previously showed that infants with PWS who received an early short course (7 days) of intranasal OT treatment improved their oral and social skills. We aim to document long-term tolerance and effects of early intranasal OT treatment on the disease trajectory. We then performed a comparative clinical trial including the 17 children who received OT as infants in our previous study and compared them to 17 PWS non-exposed children at 3 to 4 years old. Primary endpoint was the total communication score on the Vineland adaptive behavior scale version II (VABS-II). Secondary endpoints were the other domains of VABS-II, behavior scored by Childhood Behavior Check-list, feeding skills, endocrine and metabolic issues, and brain connectivity on functional magnetic resonance imaging.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u0026nbsp;\u003c/strong\u003eWe documented long-term safety of early OT treatment. The\u0026nbsp;VABS-II communication score was not different between the two groups defined as OT-exposed and non-exposed groups while a trend towards higher socialization score was found in the OT-exposed children (p=0.06). Circulating IGF-1 and HDL cholesterol were significantly higher in the OT-exposed group (p\u0026lt;0.05). OT-exposed children had normal acylated ghrelin levels which are lower than those observed in non-exposed children (p=0.06) and display higher connectivity of the orbitofrontal cortex brain region.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Early OT treatment in infants with PWS is safe up to 3 to 4 years age. OT-exposed children display better social, endocrine and metabolic outcomes. This study\u003cstrong\u003e \u003c/strong\u003edocuments for the first time in human the biological window of opportunity of early OT treatment\u0026nbsp;that may change the trajectories of PWS condition.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial Registration\u003c/strong\u003e: Clinical trial NCT03081832 Retrospectively registered \u0026nbsp; https://clinicaltrials.gov/search?cond=NCT03081832\u003c/p\u003e","manuscriptTitle":"Early oxytocin treatment in infants with Prader-Willi is safe and is associated with better endocrine metabolic and behavior outcomes.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-18 22:14:09","doi":"10.21203/rs.3.rs-4611289/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Minor revision","date":"2024-10-11T21:58:16+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2024-07-05T15:05:46+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-06-24T10:15:12+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-24T08:32:51+00:00","index":"","fulltext":""},{"type":"submitted","content":"Orphanet Journal of Rare Diseases","date":"2024-06-21T05:02:33+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"orphanet-journal-of-rare-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ojrd","sideBox":"Learn more about [Orphanet Journal of Rare Diseases](http://ojrd.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ojrd/default.aspx","title":"Orphanet Journal of Rare Diseases","twitterHandle":"@bmc","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"61450953-66a4-49a8-adec-da00f2631cff","owner":[],"postedDate":"July 18th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-03-03T16:05:11+00:00","versionOfRecord":{"articleIdentity":"rs-4611289","link":"https://doi.org/10.1186/s13023-025-03560-3","journal":{"identity":"orphanet-journal-of-rare-diseases","isVorOnly":false,"title":"Orphanet Journal of Rare Diseases"},"publishedOn":"2025-03-01 15:57:50","publishedOnDateReadable":"March 1st, 2025"},"versionCreatedAt":"2024-07-18 22:14:09","video":"","vorDoi":"10.1186/s13023-025-03560-3","vorDoiUrl":"https://doi.org/10.1186/s13023-025-03560-3","workflowStages":[]},"version":"v1","identity":"rs-4611289","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4611289","identity":"rs-4611289","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}