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)
Expected Retention
(% intake)
Calculated Retention
(per kg/day)
InUtero Accretion (/kg)
66
51
7.9
92
85
68
61
43
5.4
90-120
60-75
2.5-3.4
Enteral Protein and Energy
Requirements of Preterm Infants
Body weight, g
Protein,
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.
Ziegler E. J Pediatr Gastroenterol Nutr 2007;45:S170-4.
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)
2.8 (3)
2.4-2.6
(2.6-2.8)
PE Ratio g:100 3 (3.3)
kcal
Enteral nutrition
recommendations for VLBW
infants
Tsang RC 2005
Ca mg/kg P mg/kg Vitamin D
per day
per day IU/day
100-220 60-140 150-400a
Klein CJ (LSRO) 2002
150-220
100-130 135-338b
Agostoni C (ESPGHAN)
2010
Uauy R 2013
120-140
65-90
800-1000
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)
Micropreterm ≤29 wks
Late preterm 34-36 wks
Preterm, SGA
Post-discharge VLBW
(34-38 weeks; assuming no
accumulated nutritional deficits)
Ca mg/kg
per day
120-180
120-140
120-160
70-140
P mg/kg
per day
60-90
60-90
60-90
35-90
Vitamin D
IU/day
800-1000
400
400
400
Macromineral Balance: Enteral
Calcium (mg) at 120 kcal/kg (AAP 2013)
Ca Content (mg/dl)
Human Fortified Human Milk or
Preterm Formula
Milk
25
145
Intake (mg/kg per day)
38
220
Absorption (% intake)
60
50-60
Total absorption (mg/kg 25
per day)
Approximate retention 15-20
(mg/kg per day)
120-130
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
Solar UVB Radiation
(290-315 nanometers)
Pre-vitamin D3
Vitamin D3
DIET
Chylomicrons
Vitamin D
Liver (25 hydoxylase)
25 (OH) D
major circulating metabolite
Kidney (α
α 1 hydroxylase)
1,25 di(OH) D
Calcitriol (biologically active metabolite)
INTESTINE
BONE
Calcium, phosphorous absorption
Calcium resorption
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 P mg/kg Vitamin D
per day
per day 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)
Post-discharge formula
(22 kcal/oz)
Recommendations:
VLBW (Post-D/C)
210-235
100-130 290-470
125-150
70-80
125-130
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)
Human Milk After Discharge: Evidence
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)
The ‘Sprinkles’ Problem
Intake for 2 kg infant @ 120
kcal/kg/d
Human
Milk
(HM)
HM
enriched
with
PTDF*
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
Nutrient
HM
HM with HM with
alternated
HMF
HMF
with PTDF*
1:50
1:25
*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)
B6 (µg)
1250
250
460
100
350
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 P mg/kg Vitamin D
per day
per day 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)
Post-discharge formula
(22 kcal/oz)
Recommendations:
VLBW (Post-D/C)
210-235
100-130 290-470
125-150
70-80
125-130
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
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Thank you…