Osteopenia: Risk Factors, Prevention Strategies and

Management Options

Sharon Groh-Wargo PhD, RD, LD

Associate Professor Nutrition and Pediatrics

Senior Nutritionist

Case Western Reserve University School of Medicine

MetroHealth Medical Center, Cleveland, Ohio

May 24, 2013

Objectives

� Screen patients for medical and nutritional risk factors that contribute to the development of osteopenia

� Implement prevention strategies to minimize the incidence and severity of osteopenia

� Follow “best practice” nutritional management options to optimize outcomes

Objective One

� Screen patients for medical and nutritional risk factors that contribute to the development of osteopenia

– Definitions

– Incidence

– Screening

Important terminology

� Osteopenia: decrease in the amount of organic bone matrix (osteoid)

� Osteomalacia: lack of mineralization of the organic bone matrix

� Rickets: when loss of mineralization involves the growth plate

� Osteoporosis: decrease in bone mineral density <2.5 SD below the norm (not defined for infants)

� Metabolic bone disease: preferred term for condition in prematurity

Incidence : Osteopenia

� Up to 30% of infants under 1500 g

[Koo WW et al (Canada) 1989]

� Occurs in up to 55% of babies with BW < 1000 g [Mcintosh et al (UK) 1985]

� Prevalence is 40% in premature infants who are breastfed, in contrast to 16% of those fed with a formula designed for preterm infants and supplemented with calcium and phosphorus [Mcintosh et al (UK) 1985]

� Fractures are reported in ~10% at 36 to 40 weeks CGA [Vachharajani AJ 2009]

Osteopenia of Prematurity in ELBW Infants: S Viswanathan et al; MetroHealth Medical Center,

Cleveland, OH

� Retrospective chart review of ELBW infants admitted to the NICU between Jan 2005 and Dec 2010 (n=230)

� Cases: radiological evidence (n=71/230; 30.9% at DOL 58.2 28):

– 24/71 (33.8%) developed spontaneous fractures (DOL 100 61)

– 18/71 (25.4%) radiological rickets

� Controls: no radiological evidence (n-159/230 or 69.1%)

� Compared to controls, cases

– Were smaller at birth and more preterm

– Received more mechanical ventilation, parenteral nutrition, antibiotics, steroids and diuretics

– Had more chronic lung disease, cholestasis & higher AlkPhos levels

– Received lower average weekly intakes of kcal, pro, Ca, P and Vit D

– Had higher mortality and longer lengths of hospital stay

Causes of Osteopenia

� Low nutrient stores of calcium and phosphorus as a result of prematurity

� Increased nutrient losses of minerals as a result of renal immaturity or drug therapy

� Inadequate provision of calcium and phosphorus– Limits of solubility in TPN solutions

– Delayed feeding

– Use of unfortified human milk or non-preterm formulas

� Vitamin D deficiency

� Lack of mechanical stimulation

� Aluminum contamination of parenteral nutrition

Risk Factors

� Extreme prematurity <27 weeks GA

� Extreme low birth weight <1000g

� Parenteral nutrition >4-5 weeks

� Severe respiratory disease treated with diuretics and fluid restriction

� Long-term steroid use

� History of necrotizing enterocolitis

� Failure to tolerate fortified human milk or preterm formula

Screening and Assessment (Vachharajani AJ 2009; Groh-Wargo, Thompson, Cox, 2000)

� Markers of bone formation

– Alkaline phosphatase: ≤ 500 U/L

– Serum phosphorus: ≥ 5.0 mg%

– Serum 25 (OH) vitamin D: ≥ 20 ng/ml

� Markers of bone resorption

– Urinary calcium: <1.2 mmol/L (4.8mg/dl)

– Tubular resorption phosphorus: <85-90%

� Imaging and absorptiometry

– Serial radiographs, DEXA, Quantitative ultrasonography (SOS)

Recommended screening schedule for VLBW (AAP 2013)

� Starting at ~4-5 weeks of age and then blood levels weekly/biweekly; radiographs Q5-6 wks

� Alkaline Phosphatase levels >800 IU/L, serum phosphorus ~4 mg/dl, or clinical evidence of fractures should lead to radiographic evaluation for rickets

� Assess Vitamin D when cholestasis is present and target for levels >20 ng/ml

� Treatment should focus on maximizing calcium and phosphorus intake

Objective Two

� Implement prevention strategies to minimize the incidence and severity of osteopenia

– Key nutrients

– Recommended intakes

Key nutrients important to bone health

� Protein and energy

� Calcium

� Phosphorus (primary nutritional problem)

� Vitamin D

� Miscellaneous: Vitamin K, Fluoride, etc

Sources of Recommended Intakes for Newborns

� Uauy R (Ed). Global Neonatal Consensus Symposium: Feeding the Preterm Infant. Journal of Pediatrics:162(3); Supplement 1. March, 2013.

� Tsang RC, Uauy R, Koletzko B, Zlotkin SH, eds. Nutrition of

the Preterm Infant, 2nd Edition. Digital Publishing, Cincinnati, Ohio. 2005

� ESPGHAN (Agostoni C et al, JPGN. 2010;50:85-91)

� American Academy of Pediatrics. (Kleinman RE (ed). Nutrition

needs of the preterm infant. In, Pediatric Nutrition Handbook, 6th Ed. Elk Grove Village, IL: AAP, 2009. p 79-112)

� Dietary Reference Intakes (term infants) (IOM) http://iom.edu/Home/Global/News%20Announcements/DRI

[accessed 3/7/11]

Building a Strong Structure

Lourdes Pereda, MD. USF, FL 2002

Macrominerals: Physiological Role

� Calcium: Over 95% in bones and teeth; remainder in blood, ECF, muscle – mediates vascular contraction/dilation, muscle contraction, nerve transmission and glandular secretion

� Phosphorus – structural – over 85% in bone; functional – most of the remainder is throughout soft tissue mostly in phospholipids of RBCs and plasma lipoproteins; small amount (~1%) as inorganic phosphate which is a primary source from which cells in all tissues derive high-energy phosphate (ATP)

Reasonable Nutrient Intakes: Parenteral (Tsang, Uauy, Koletzko and Zlotkin, 2005)

� ELBW

� Energy (kcal/kg/d)

– Day 0: 40-50

– Transition: 75-85

– Growing: 105-115

� Protein (g/kg/d)

– Day 0: 2

– Transition: 3.5

– Growing: 3.5-4.0

� VLBW

� Energy (kcal/kg/d)

– Day 0: 40-50

– Transition: 60-70

– Growing: 90-100

� Protein (g/kg/d)

– Day 0: 2

– Transition: 3.5

– Growing: 3.2-3.8

Macrominerals: Parenteral Intake Recommendations (Tsang et al, 2005)

Day 0 Transition Growing

Ca (mg/kg) (mEqX40/2=mg)

20-60 60 60-80

P (mg/kg) (mmoleX31=mg)

0 45-60 45-60

Mg (mg/kg) (mEqX24/2=mg)

0 4.3-7.2 4.3-7.2

Macromineral IV Sources

� Calcium: Calcium gluconate (9% elemental calcium). For example: 300 mg calcium gluconate = 27 mg elemental calcium; Ca:P 1.3:1 to 1.7:1

� Phosphorus: Sodium and potassium phosphate. NaPhos significantly lower than KPhos in aluminum (5977 vs. 16598 µg/l (Sedman et al, 1985)

Macromineral IV Balance (mg)

Ca P Mg

Concentration ( /liter) 600 465 72

Delivery (per kg/day at 110 ml/kg/day)

66 51 7.9

Expected Retention

(% intake)

92 85 68

Calculated Retention

(per kg/day)

61 43 5.4

InUtero Accretion (/kg) 90-120 60-75 2.5-3.4

Enteral Protein and Energy Requirements of Preterm Infants

Ziegler E. J Pediatr Gastroenterol Nutr 2007;45:S170-4.

Body weight, gProtein, g/kg/d

Energy, kcal/kg/d P/E, g/100 kcal

500-700 4.0 105 3.8

700-900 4.0 108 3.7

900-1200 4.0 119 3.4

1200-1500 3.9 127 3.1

1500-1800 3.6 128 2.8

1800-2200 3.4 131 2.6

P/E = Ratio of protein to energy, expressed as grams of protein per 100 kcal.

Daily Protein and Energy needs based on age (and need for catch-up)(Rigo and Senterre, J Peds 2006)

26-30 weeks

30-36 weeks

36-40 weeks

Protein g/kg 3.8-4.2 (4.4)

3.4-3.6 (3.6-4)

2.8-3.2 (3-3.4)

Energy kcal/kg

126-140 (134)

121-128 (120-130)

116-123 (115-121)

PE Ratio g:100 kcal

3 (3.3) 2.8 (3) 2.4-2.6 (2.6-2.8)

Enteral nutrition recommendations for VLBW infants

Ca mg/kg per day

P mg/kg per day

Vitamin D IU/day

Tsang RC 2005 100-220 60-140 150-400a

Klein CJ (LSRO) 2002 150-220 100-130 135-338b

Agostoni C (ESPGHAN) 2010

120-140 65-90 800-1000

Uauy R 2013 120-160 60-90 400-1000

AAP 2013 150-220 75-140 200-400

aAim for 400 IU/d; b90-125 IU/kg, above for a 1.5 kg

Enteral nutrition recommendations for special populations of infants (Uauy R 2013)

Ca mg/kg per day

P mg/kg per day

Vitamin D IU/day

Micropreterm ≤29 wks 120-180 60-90 800-1000

Late preterm 34-36 wks 120-140 60-90 400

Preterm, SGA 120-160 60-90 400

Post-discharge VLBW (34-38 weeks; assuming no accumulated nutritional deficits)

70-140 35-90 400

Macromineral Balance: Enteral Calcium (mg) at 120 kcal/kg (AAP 2013)

Human

Milk

Fortified Human Milk or Preterm Formula

Ca Content (mg/dl) 25 145

Intake (mg/kg per day) 38 220

Absorption (% intake) 60 50-60

Total absorption (mg/kg per day)

25 120-130

Approximate retention (mg/kg per day)

15-20 100-120

Third Trimester In-Utero Accretion (mg/kg per day): 90-120

Bone Mineral Content in Preterm Infants (Atkinson 2005)

7-dehydrocholesterol in skin

Pre-vitamin D3

Vitamin D3

Vitamin D

25 (OH) Dmajor circulating metabolite

1,25 di(OH) DCalcitriol (biologically active metabolite)

INTESTINECalcium, phosphorous absorption

BONECalcium resorption

DIETChylomicrons

Solar UVB Radiation(290-315 nanometers)

Liver (25 hydoxylase)

Kidney (αααα 1 hydroxylase)

AAP Recommendations 2008

� WHO: All Breastfed infants and any formula fed infant taking < 1 quart or liter per day

� WHEN: Within the first few days of life

� WHAT: 400 IU vitamin D per day supplement

� HOW: Infant ADC drop 1 ml per day

� WHY: Increasing incidence of vitamin D deficiency in the maternal population has resulted in deficiency in newborns

� Wagner C, Greer FR, Section Breastfeeding and CON. Pediatrics 2008 122:1142-1152.

Forms of Vitamin D

� Cholecalciferol: Vitamin D3

– Infant formulas and human milk

– Baby Ddrops (1 drop provides 400, 1000 or 2000 IU)

– Vi-sol and Just D drops (1 ml = 400 IU)

– AquADEKs and SourceCF drops (1 ml = 400 IU)

� Ergocalciferol (UV irradiation of ergosterol from yeast): Vitamin D2

– Calciferol and Drisdol (1 ml = 8000 IU)

Vitamin K and Bone

� Function

– Vitamin K dependent proteins: osteocalcin (or bone Gla protein) as well as matrix Gla protein of the skeleton

– Gla proteins are required for calcium mediated interactions

� Storage: limited compared to other fat soluble vitamins

Vitamin K and Bone

� Sources

– Newborn IM injection 0.5-1 mg

– Pediatric parenteral multi-vitamins provide ~ 60-130 mcg per day (1.5-3.25 ml per day)

– Concentration low in HM <1mcg/dl

� Requirements/Recommendations

– Tsang 2005 VLBW/ELBW • Parenteral: 10 mcg/kg per day

• Enteral: 8-10 mcg/kg per day

– US DRI 0-12 months 2-2.5 mcg/day

Fluoride

� Affinity for calcified tissues; ingestion during pre-eruptive development of the teeth has a cariostatic effect; post-eruptive effect mainly through reduced acid production of plaque bacteria; unique ability to stimulate bone formation; no specific recommendations for preterm infants

� Emerging evidence for parenteral fluoride (Nielsen FH Gastroenterology 2009)

Other micronutrients important to bone health

� Vitamin C, Copper, and Zinc

� Cofactors for the synthesis or cross-linking of matrix proteins

� Interference with cross-linking results in structurally weak bone

� Deficiency during growth periods results in the most profound impact

� Ross AC et al, Modern Nutrition in Health and Disease, 11th Ed. Pg 1221

Objective Three

� Follow “best practice” nutritional management options to optimize outcomes– Parenteral nutrition

• Calcium:Phosphorus solubility

• Phosphorus shortages

• Aluminum contamination

– Human milk: fortification

– Formula feeding: choice of formula

– Supplementation: Ca and P; Vitamin D

Calcium Phosphate Solubility Curves

Fitzgerald KA, MacKay MW. Calcium and phosphate solubility in neonatal

parenteral nutrient solutions containing TrophAmine. Am J Hosp Pharm 1986

Factors that Increase Solubility of Calcium and Phosphorus

� Very acidic pH

� Higher [concentration] of dextrose & protein

� Cysteine in TPN

� Cooler temperature

� Ca and P concentration and ratio

� Addition of P before Ca

� Fat emulsion by IV piggyback

Parenteral Nutrition Solution Shortages: General Strategies

� Prioritize: ELBW, neonates, pediatric patients

� Individualize: reconsider automatic protocols

� Centralize: minimize waste by compounding in a central location

� Ration: for example, 75% of dose

� Substitute: enteral feeding, fortification ASAP

� Observe: be alert for deficiency; monitor

Holcombe B et al. 2011 JPEN 35(4):434-436; Holcombe B et al. 2012 JPEN 36:44S-47S.

Case Report: Hypercalcemia associated with phosphate deficiency in the neonate (Miller RR, Menke JA, Mentser MI. J Peds 1984)

� Male infant; 28 wk GA and 680g BW

� TPN started DOL5: D10%, AA, Mg, Ca, D

� DOL 16: PDA, CHF, enlarged liver, abdominal distention, Serum Ca 21.6 mg.dl

� DOL 20: Lethargic, edematous, murmur, abnormal electrocardiogram, continued hypercemia despite decreased calcium in PN, serum phosphorus <1 mg/dl

Case Report: Hypercalcemia associated with phosphate deficiency in the neonate (Miller RR, Menke JA, Mentser MI. J Peds 1984)

Phosphorus deficiency: Signs and Symptoms

� Respiratory muscle function– Impaired diaphragmatic contractility

– Respiratory failure

– Failure to wean from mechanical ventilation

� Cardiovascular system– Decreased myocardial contractility

– Increased inotropic requirement

– Arrythmias

� Central nervous system– Paralysis, weakness, paresthesias, seizures

� Increased mortality

IV Phosphate Critical Shortage: Clinical Strategies

� Encourage Enteral Feeding– Begin feeds as soon as possible

– Fortify human milk to 22/kcal at 50 ml/kg/day of feed

� Judicious use of TPN– Provision of daily IV fat emulsion to all PN patients (IV fat emulsions

contain 15 mmol/L of phosphate)

– IV Fluids and enteral feeds instead of TPN ≥ 34 wks

– For babies >1 kg , stop TPN at 80 ml/kg/day

� Modify TPN for larger infants (>1500g BW)– no phosphorous

– Monitor phosphorous levels – critical replacement if serum level <2.0

Aluminum

� Contaminant in parenteral solutions

� Associated with impaired neurological development and decreased bone calcium uptake

� Preterm infants may be a risk of Al toxicity due to renal immaturity, neurological/bone development

� FDA rules mandating labeling of content became effective in 2004

� Recommended IV exposure is ‘no more than 5 mcg/kg per day’

� Goal is to label products and limit exposure

Strategies to Minimize Aluminum Load

� Use sodium phosphate in place of potassium phosphate as source of phosphate

� Use solutions packaged in plastic instead of glass as much as possible

� Compare products and choose carefully

� Use multivitamin infusion with lowest aluminum concentration

� These steps minimize the aluminum load but do not decrease it to the recommended level

Good News – Bad News Regarding IV Aluminum Exposure

� Reported aluminum concentration is maximum possible at product expiration

� Measured aluminum content is significantly less than calculated aluminum content

� Measured aluminum of 40 neonatal TPN solutions were ~50% of calculated value (Poole RL et al JPGN 2010)

� Actual intake still exceeded recommended safe limit of <5 mcg/kg/d (~18 mcg/kg/d)

Human Milk Fortification

� WHO

� WHAT

� WHERE

� WHEN

� WHY

WHO should receive human milk fortification?

� ≤ 34 weeks’ gestation� ≤ 1800 g birth weight� Parenteral nutrition > 2 weeks� > 1800 g birth weight with suboptimal

growth and/or feeding volume restriction and/or significant medical/surgical complications

[Schanler RJ and Abrams SA, 1995; Schanler RJ et al, 1999; Atkinson SA, 2000; Abrams SA 2013]

WHAT are the options for fortification?

� Commercial human milk fortifier (1:25) (powder and concentrated liquid) (Kuschel CA, Harding JE.

Cochrane Database Syst Rev. 2004;(1):CD000343)

� Commercial nutrient dense preterm formula (1:1 etc) (liquid) (Moyer-Mileur L et al JPGN 1992; Lewis J et al J

Invest Med 2010)

� Concentrated donor human milk enriched with minerals (frozen liquid) [Prolacta Bioscience

http://prolacta.com accessed 8/23/11] (~$40/oz) (Sullivan S et

al. J Pediatr 2010)

WHAT are the options for fortification? (continued)

� Individualized:

– Based on milk analysis (Polberger S et al. JPGN 1999; deHalleux V et al. Arch Pediatr 2007)

– Based on nutrient content (Pohlandt F Pediatr Res 1993)

� Adjustable: based on BUN (Arslanoglu S et al. J

Perinatol 2006)

WHERE should human milk fortifier be added to human milk?

� The addition of human milk fortifier to expressed human milk at the bedside is not advised (Ohio Department of Health, The American Dietetic Association, ASPEN)

� A NICU “Milk lab” as a separate location is ideal to insure

– Cleanliness and safety of expressed human milk

– Accuracy and adequacy of mixing

WHEN should human milk fortification start and stop?

� Start– As early as 25 ml/day of human milk (Univ Iowa)

– As late as attainment of full enteral feedings (150 ml/kg per day)

– Most usual start time is attainment of 80-100 ml/kg per day enteral feedings

� Stop– As early as a few days prior to NICU discharge (most

usual)

– As late as 52 weeks post-conceptional age or weight of 3.5 kg, whichever comes first

WHY do we give human milk fortification?

� Inadequate concentration of– Protein

– Minerals, for example

• Calcium

• Phosphorus

• Zinc

• Sodium

HMF Meta-Analysis: BMC

HMF Meta-Analysis: NEC

Intake of Ca, P and Vitamin D from Selected Feedings at 160 ml/kg/d

Ca mg/kg per day

P mg/kg per day

Vitamin D IU/day

Unfortified HM 20 kcal/oz 30-40 20-25 2-3

Fortified HM 24 kcal/oz 180-220 100-125 280-380

Preterm Formula

(24 kcal/oz)

210-235 100-130 290-470

Post-discharge formula (22 kcal/oz)

125-150 70-80 125-130

Recommendations: VLBW (Post-D/C)

150-220 (70-140)

75-140 (35-90)

200-400 (400)

Human Milk (HM) After Discharge: Evidence

� Feeding HM is associated with improved neurocognitive outcomes but decreased growth (O’Connor DL 2003, Lucas A 2001)

� Feeding fortified HM improves nutrient intake, bone mineralization, visual acuity and length and head growth compared to feeding HM without fortification (O’Connor DL 2008, Aimone A 2009, O’Connor DL 2012)

� Feeding fortified HM may not improve overall growth compared to feeding preterm formula (Zachariassen G 2011)

� Fortification of HM following discharge does not interfere with breastfeeding success (O’Connor DL 2008; Zachariassen G 2011)

Anthropometric measurements of human milk-fed infants sent home (study day 1) fed human milk alone (- -) or with approximately half of the human milk–fed mixed with a multi-nutrient fortifier (–) for 12 weeks. Asterisks denote a significant difference between feeding groups at a specific time point. (Aimone A et al 2009)

Human Milk After Discharge: Evidence

The ‘Sprinkles’ Problem

Intake for 2 kg infant @ 120 kcal/kg/d

Nutrient

Human

Milk

(HM)

HM

enriched

with

PTDF*

HM

alternated

with PTDF*

HM with

HMF

1:50

HM with

HMF

1:25

Volume, mL/kg 175 150 165 165 150

Protein, g/kg 1.6 1.9 2.6 2.5 2.9

Ca, mg/kg 49 64 92 124 197

P, mg/kg 26 35 52 69 110

Zn, mcg/kg 210 412 848 852 1470

Vit D, IU/d 4 36 95 216 411

*PTDF: preterm discharge formula; Term HM; Estimated needs at D/C: Protein (2.8-3.4 g/kg); Ca (100-220 mg/kg); P (60-140 mg/kg); Zn (1000-3000 mcg/kg); Vitamin D (>400 IU/d)

Who should be fortified at discharge?

� VLBW infants still <2 kg at discharge

� Evidence of nutritional deficiency and/or osteopenia

– BUN <10 mg/dl

– Phosphorus <6 mg/dl

– Alkaline Phosphatase >600 U/L

– X-ray evidence of bone demineralization

� Growth at less than the intrauterine rate of 15 g/kg per day

Formula Choice

Preterm Formula (PF) and/or Preterm Discharge Formula (PTDF) for Feeding PT Infants after Discharge: Advantages

� Improved nutritional intake of key nutrients

� Increased weight, length and head circumference growth

� Improved bone mineral content (BMC)

� Enhanced lean body mass accretion

� Normalization of biochemical indices of nutritional status

Selected Nutrient Levels (per 100 kcal) for Three Formulas

Preterm Formula (PF)

Preterm Discharge Formula (PTDF)

Standard Term Formula

(TF)

Kcal/oz 24 22 20

Pro (gm) 3 (3.3) 2.8 2.1

A (IU) 1250 460 350

B6 (µg) 250 100 60

Ca (mg) 180 105 78

Zn (mg) 1.5 1.2 0.75

Intake of Ca, P and Vitamin D from Selected Feedings at 160 ml/kg/d

Ca mg/kg per day

P mg/kg per day

Vitamin D IU/day

Unfortified HM 20 kcal/oz 30-40 20-25 2-3

Fortified HM 24 kcal/oz 180-220 100-125 280-380

Preterm Formula

(24 kcal/oz)

210-235 100-130 290-470

Post-discharge formula (22 kcal/oz)

125-150 70-80 125-130

Recommendations: VLBW (Post-D/C)

150-220 (70-140)

75-140 (35-90)

200-400 (400)

PF and PTDF After Discharge: Evidence

� Feeding PF for 8 weeks following discharge results in improved BMC compared to feeding PTDF or TF (Chan G 1993; Picaud J-C 2008)

� Feeding PTDF for 3-6 months following discharge results in improved weight and length growth, better BMC, and increased lean body mass accretion but no difference in fat mass or central adiposity compared to feeding TF or unfortified HM (Brunton JA 1998; Cooke RJ 2010; Amesz EM 2010)

PF and PTDF After Discharge: Evidence (cont)

� Feeding PTDF for 9-12 months following discharge results in improved weight, length and head circumference growth and better BMC in LBW infants, especially those <1250g at birth, compared to feeding TF or unfortified HM (Bishop NJ 1993, Carver JD 2001; Lucas A 2001)

� Feeding PF supplemented with LC-PUFAs until term and PTDF supplemented with LC-PUFAs until 12 months corrected age results in improved lean body mass accretion compared to feeding PF and PTDF without supplemental LC-PUFAs (Groh-Wargo S 2005)

Brunton JA et al 1998

Calcium & Phosphorus Supplementation: VLBW on low mineral feedings� Calcium (elemental):

– Initial: 20 mg/kg per day– Maximum: 70-80 mg/kg per day– Source: Ca glubionate (23 mg/ml; high osmolality) or

Ca carbonate (100 mg/ml; less bioavailable)

� Phosphorus (elemental):– Initial: 10-20 mg/kg per day– Maximum: 40-50 mg/kg per day– Source: IV potassium phosphate (31 mg P/mmol)

� Combination salts: Ca tribasic P (0.39 mg Ca & 0.28 mg P/mg powder)

� Goal to provide approximate intake of fortified human milk or preterm formula

Steps to Minimize Osteopenia

� Maximize solubility in TPN solutions

� Limit calcium-losing medications

� Introduce priming enteral feedings ASAP

� Use human milk fortification

� Provide adequate vitamin D

� Continue enriched nutrient following discharge as appropriate

� Monitor phosphorus and alkaline phosphatase

Summary of 2013 Recommendations for Management of Osteopenia from the AAP� Risk: <27 wks or <1000g at birth

� Screening: Start at 4 weeks for all VLBW– X-ray if alkaline phosphatase (APA) >800 IU/L

– If P consistently <4, follow and consider supplement

� Feeding: FHM or PT formula if <1800 g BW

� Discharge: PDF if VLBW; follow APA for HM fed

� Vitamin D: 400-1000 IU/d

� Management of Osteopenia Diagnosis– Maximize Ca and P intake

– minimizing factors leading to bone mineral loss

– gentle handling

Cases: Osteopenia

� Case 1: 638g BW 24 wk GA (AGA)– Intolerance to preterm formula; family hx of allergy

– TPN 50 days (average 25-30 for BW and GA)

– Lasix therapy 98 days

� Case 2: 543g BW 27 wk GA (SGA)– Expressed human milk with late human milk fortification

– Decreasing milk supply

� Case 3 771g BW 24 wk GA (AGA)– BPD/ steroid therapy/fluid restriction

– Fractured left clavicle DOL 83

Summary: Osteopenia

� Prematurity is a primary cause of osteopenia occurring in 30-50% of VLBW infants

� Key nutrients include protein, calcium, phosphorus and vitamin D

� Parenteral nutrition provides inadequate amounts of calcium and phosphorus

� Human milk is the ideal feeding for nearly all newborns but requires fortification to meet the nutritional needs of VLBW infants

� Supplementation with 400 IU/day of vitamin D is routine

References

� Abrams SA and the Committee on Nutrition, AAP. Calcium and Vitamin D Requirements of Enterally Fed Preterm Infants. Pediatrics online. www.pediatrics.org/cgi/doi/10.1542/peds.2013-0420

� Begany M. Identification of fracture risk and strategies for bone health in the neonatal intensive care unit. Top Clin Nutr. 2012. 27(3):231-247.

� Vachharajani AJ et al. Metabolic bone disease of prematurity. 2009. NeoReviews. 10(8):e402-410.

� Uauy R (Ed). Global Neonatal Consensus Symposium: Feeding the Preterm Infant. Journal of Pediatrics. 162(3):Supplement 1, 2013.

Thank you…