Maternal-administered physical activity enhances bone mineral acquisition in premature very low birth weight infants

Effect of physiotherapy on the promotion of bone mineralization in preterm infants: a randomized controlled trial

Preterm infants have a low level of bone mineralization compared to those born at term. The purpose of the present study was to investigate the effect of reflex locomotion therapy (RLT) on bone mineralization and growth in preterm infants and compare its effect to other physiotherapy procedures. Forty-six preterm infants born at 29–34 weeks were randomized into three groups: one group received RLT (n = 17); the other group received passive movements with gentle joint compression (n = 14); and the control group received massages (n = 15). All the treatments were performed at the neonatal unit for one month. The main outcome measure was bone mineralization, which was measured using the tibial speed of sound (Tibial-SOS). All the groups were similar in terms of gestational age (31.8 ± 1.18), birth weight (1,583.41 ± 311.9), and Tibia-SOS (1,604.7 ± 27.9) at the beginning of the intervention. At the end of the study, significant differences were found among the groups in the Tibial-SOS [F(4,86) = 2.77, p = 0.049, η_p² = 0.114] in terms of the benefit to the RLT group. In conclusion, RLT has been effective at improving Tibial-SOS levels and has been more effective than other physical therapy modalities; therefore, it could be considered an effective physiotherapeutic modality for the prevention and treatment of osteopenia from prematurity.

Effect of physical therapy on bone remodelling in preterm infants: a multicenter randomized controlled clinical trial

Background

Preterm infants have a low level of bone mineralization compared to those born at term, since 80% of calcium incorporation occurs at the end of pregnancy. The purpose of the present study was to investigate the effect of reflex locomotion therapy on bone modeling and growth in preterm infants and to compare its effect with those of other Physiotherapy modalities.

Methods

A multicentre randomized controlled clinical trial was conducted (02/2016 – 07/2020). 106 preterm infants born at the Virgen de la Arrixaca University Clinical Hospital, the General University Hospital of Elche and the Torrecárdenas University Hospital of Almería, between 26 and 34 weeks with hemodynamic stability, complete enteral nutrition and without any metabolic, congenital, genetic, neurological or respiratory disorders were evaluated for inclusion. Infants were randomly assigned to three groups: one group received reflex locomotion therapy (EGrlt); another group received passive mobilizations with gentle joint compression (EGpmc); and the control group received massage (CG). All treatments were carried out in the neonatal units lasting one month. The main outcome measure was bone formation and resorption measured with bone biomarkers. A mixed ANOVA was used to compare the results of bone biomarkers, and anthropometric measurements.

Results

Infants were randomized to EGrlt (n = 38), EGpmc (n = 32), and CG (n = 36). All groups were similar in terms of gender (p = 0.891 female 47.2%), gestational age (M = 30.753, SD = 1.878, p = 0.39) and birth weight (M = 1413.45, SD = 347.36, p = 0.157). At the end of the study, significant differences were found between the groups in their interaction in bone formation, measured with osteocalcin [F (2,35) = 4.92, p = 0.013, η_p² = 0.043], in benefit of the EGrlt.

Conclusions

Reflex locomotion therapy has been effective in improving bone formation, more so than other Physiotherapy modalities. Therefore, reflex locomotion therapy could be considered one of the most effective physiotherapeutic modalities for the prevention and treatment of osteopenia of prematurity.

Trial registrstion

Trial retrospectively registered at ClinicalTrials.gov. First posted on 22/04/2020. Registration number: NCT04356807.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03402-2.

Effects of Self-Regulated Physical Activity in Premature Infants on Bone Density and Length of Stay: A Pilot Study

IMPORTANCE

Premature infants are not prepared developmentally, physically, or cognitively with the multiple survival skills of the typical newborn.

OBJECTIVE

To determine whether physical activity generated spontaneously by premature infants stretching against the resistance of "prepod" garments is as effective as exercises provided by therapists in slowing bone density loss.

DESIGN

Preterm very low birth weight infants were placed in two nonrandomized parallel groups according to birth age.

SETTING

Infants routinely started in a traditional intense intervention setting and graduated to a special care section with private rooms that allowed parents to remain with their child.

PARTICIPANTS

Healthy infants without medical complications, born between 28 and 32 wk postmenstrual age.

INTERVENTION

The control group received traditional exercises. The experimental group wore a prepod almost 24 hr a day. Outcomes and Measures: An ultrasound of the tibia was obtained at 31 to 32 wk and 4 wk later. Weight gain, head circumference growth, and length of stay (LOS) were also measured.

RESULTS

Although not statistically significant, the ultrasound results showed that the prepod group had less loss of bone density than the traditional therapy exercise group. The desired outcome was for pods to be as effective at reducing bone loss as traditional exercise, so the results exceeded expectations. The unexpected, and more notable, finding was a striking drop in LOS for the prepod group.

CONCLUSIONS AND RELEVANCE

Spontaneous exercise by premature infants decreases bone loss and LOS. Better bone health and increased developmental maturity increase the chances of a positive developmental outcome and save the hospital significant expense. What This Article Adds: The prepod is a simple, cost-effective, noninvasive treatment tool occupational therapy practitioners can use to support a premature infant's development. This study has considerable potential to affect how infants are served, both developmentally and financially.

Physical Therapy to Prevent Osteopenia in Preterm Infants: A Systematic Review

Background: During the last trimester of pregnancy, about 80% of the infant’s calcium is incorporated, and for this reason, preterm infants have less bone mineralization compared to those born at term. The aim of the present systematic review was to identify, evaluate and summarize the studies that deal with the effect of physiotherapy modalities in the prevention and treatment of osteopenia in preterm infants. Methods: A comprehensive search (09/2019–02/2021) using PubMed, Web of Science, SCOPUS, ProQuest, SciELO, Latindex, ScienceDirect, PEDro and ClinicalTrials.gov was carried out. The following data were extracted: The number of participants, characteristics of the participants, design, characteristics of the intervention, outcome measures, time of evaluation and results. A non-quantitative synthesis of the extracted data was performed. The methodological quality and risk of bias were assessed using a PEDro scale and ROB-2 scale, respectively. Results: A total of 16 studies were analyzed, presenting a methodological quality that ranged from 3 to 8 points, and all showed some concerns regarding their risk of bias. Almost all studies (15/16) used passive mobilizations with joint pressure to prevent osteopenia, but they differed in the intensity and frequency of application. Conclusions: A daily exercise program of passive mobilizations with joint pressure, improves bone mineralization in preterm infants admitted to neonatal units.

Effects of Maternal Exercise During Pregnancy on Perinatal Growth and Childhood Obesity Outcomes: A Meta-analysis and Meta-regression

BACKGROUND

Perinatal growth abnormalities program susceptibility to childhood obesity, which is further exaggerated by maternal overweight and obesity (MO) during pregnancy. Exercise is highly accessible, but reports about the benefits of maternal exercise on fetal growth and childhood obesity outcomes are inconsistent, reducing the incentives for pregnant women to participate in exercise to improve children's perinatal growth.

OBJECTIVE

This systematic review and meta-analysis aims to establish evidence-based efficacy of exercise in mothers with normal weight (MNW) and MO during pregnancy in reducing the risks of perinatal growth abnormalities and childhood obesity. In addition, the impacts of exercise volume are also assessed.

METHODS

The PubMed, ScienceDirect, Web of Science, and Cochrane Library databases were searched from inception to February 15, 2020. We included randomized controlled trials with exercise-only intervention or exercise with other confounders in pregnant MNW (body mass index, BMI 18.5-24.9 kg/m²) and MO (BMI ≥ 25 kg/m²), which were further subgrouped in the meta-analysis. Primary outcomes included birth weight, preterm birth, small for gestational age (SGA), large for gestational age (LGA), infant and childhood weight, and childhood obesity. A linear meta-regression analysis was also used to explore the effects of exercise volume on outcomes.

RESULTS

99 studies were included in the meta-analysis (n = 596,876), and individual study quality ranged from fair to good according to the Newcastle-Ottawa scale assessment. Exercise only interventions in MNW reduced preterm birth by 15% (26 studies, n = 76,132; odds ratio [OR] 0.85; 95% CI 0.72, 1.01; I² = 83.3%), SGA by 17% (33 studies, n = 92,351; OR 0.83; 95% CI 0.71, 0.98; I² = 74.5%) and LGA by 17% (29 studies, n = 84,310; OR 0.83; 95% CI 0.74, 0.95; I² = 60.4%). Exercise only interventions in MO reduced preterm birth by 33% (2 studies, n = 3,050; OR 0.67; 95% CI 0.70, 0.96; I² = 0%), SGA by 27% (8 studies, n = 3,909; OR 0.73; 95% CI 0.50, 1.05; I² = 40.4%) and LGA by 55% (9 studies, n = 81,581; OR 0.45; 95% CI 0.18, 1.11; I² = 98.3%). Exercise only interventions in MNW reduced childhood obesity by 53% (3 studies, n = 6,920; OR 0.47; 95% CI 0.36, 0.63; I² = 77.0%). However, no significant effect was observed in outcomes from exercise confounders in either MNW or MO. In the meta-regression, the volume of exercise-only intervention in MNW was negatively associated with birth weight, greatly driven by volumes more than 810 metabolic equivalents (MET)-min per week. Other outcomes were not associated with exercise volume.

CONCLUSIONS

This systematic review and meta-analysis suggests that exercise during pregnancy in both MNW and MO safely and effectively reduce the risks of preterm birth, SGA, and LGA. Furthermore, MNW exercise also reduces the risk of childhood obesity. Overall, regardless of prepregnancy BMI, maternal exercise during pregnancy provides an excellent opportunity to mitigate the high prevalence of adverse birth outcomes and childhood obesity.

Metabolic Bone Disease in Premature Neonates: An Unmet Challenge

Metabolic bone disease (MBD) is an important cause of morbidity in premature, very low birth weight (VLBW) and sick infants and, if left undiagnosed, may lead to structural deformities and spontaneous fractures. MBD is defined as impaired bone mineralization in a neonate with lower than expected bone mineral levels in either a fetus or a neonate of comparable gestational age and/or weight, coupled with biochemical abnormalities with or without accompanying radiological manifestations. MBD has been reported to occur in 16% to 40% of extremely low birth weight neonates and presents by 6-16 weeks after birth. Insufficient calcium and phosphorous stores during the phase of accelerated growth predispose to MBD in neonates along with the use of some medications such as caffeine or steroids, prolonged parenteral nutrition and chronic immobilization. Enhanced physical activity in preterm infants facilitates bone mineralization and weight gain. Biochemical abnormalities tend to worsen significantly, as the severity of disease progresses. These abnormalities may include hypocalcemia, hypophosphatemia, hyperphosphatasia and secondary hyperparathyroidism. In addition, urinary phosphate wasting and hypovitaminosis D can be additional complications. Conversely, biochemical abnormalities may not be accompanied by rachitic changes. Newer diagnostic modalities include non-invasive bone densitometry by quantitative ultrasound over the mid-tibial shaft. The management of MBD includes adequate calcium, phosphorous and vitamin D supplementation, along with optimum nutrition and physical activity. Similarly, preventive strategies for MBD should target nutritional enhancement in combination with enhanced physical activity. MBD usually results in preventable morbidity in preterm and VLBW neonates. Treatment consists of optimum nutritional supplementation and enhanced physical activity.

Risk factors of bone mineral metabolic disorders

Bone remodeling is a complex process which integrates different stimuli factors such as mechanical, nutritional and hormonal factors as well as cytokines and growth factors. Bone health depends on an adequate balance between all these factors. The typical bone pathology of the newborn is the metabolic bone disease of prematurity, favored by a lack of mineral accretion in the third trimester of gestation. The intrinsic defects of the bone tissue (primary osteoporosis) are usually of genetic or idiopathic origin and can affect both the term and the preterm newborn. Other risk factors for osteopenia (secondary osteoporosis) include maternal or gestational factors, nutritional deficits (calcium, phosphorus, vitamin D), endocrinological alterations, use of certain medications antagonistic to bone metabolism, mechanical factors and chronic diseases (renal or hepatic insufficiency, intestinal malabsorption, collagen or metabolic diseases). This review examines the risk factors of developing bone metabolic disorders in neonates.

Breech presentation is associated with lower adolescent tibial bone strength

We compared bone outcomes in adolescents with breech and cephalic presentation. Tibia bone mineral content, density, periosteal circumference, and cross-sectional moment of inertia were lower in breech presentation, and females with breech presentation had lower hip CSA. These findings suggest that prenatal loading may exert long-lasting influences on skeletal development.

INTRODUCTION

Breech position during pregnancy is associated with reduced range of fetal movement, and with lower limb joint stresses. Breech presentation at birth is associated with lower neonatal bone mineral content (BMC) and area, but it is unknown whether these associations persist into later life.

METHODS

We examined associations between presentation at onset of labor, and tibia and hip bone outcomes at age 17 years in 1971 participants (1062 females) from a UK prospective birth cohort that recruited > 15,000 pregnant women in 1991-1992. Cortical BMC, cross-sectional area (CSA) and bone mineral density (BMD), periosteal circumference, and cross-sectional moment of inertia (CSMI) were measured by peripheral quantitative computed tomography (pQCT) at 50% tibia length. Total hip BMC, bone area, BMD, and CSMI were measured by dual-energy X-ray absorptiometry (DXA).

RESULTS

In models adjusted for sex, age, maternal education, smoking, parity, and age, singleton/multiple births, breech presentation (n = 102) was associated with lower tibial cortical BMC (- 0.14SD, 95% CI - 0.29 to 0.00), CSA (- 0.12SD, - 0.26 to 0.02), BMD (- 0.16SD, - 0.31 to - 0.01), periosteal circumference (- 0.14SD, - 0.27 to - 0.01), and CSMI (- 0.11SD, - 0.24 to 0.01). In females only, breech presentation was associated with lower hip CSA (- 0.24SD, - 0.43 to 0.00) but not with other hip outcomes. Additional adjustment for potential mediators (delivery method, birthweight, gestational age, childhood motor competence and adolescent height and body composition) did not substantially affect associations with either tibia or hip outcomes.

CONCLUSIONS

These findings suggest that prenatal skeletal loading may exert long-lasting influences on skeletal size and strength but require replication.

The long-term impact of very preterm birth on adult bone mineral density

Introduction

Preterm infants are at increased risk of osteopenia of prematurity due to insufficient bone mineral accretion. Data on long term effects of prematurity on bone health are conflicting. This study aimed to compare bone mineral density (BMD) in young adults born very preterm and full-term controls and to examine factors associated with long-term bone health.

Methods

This observational cross-sectional study enrolled 101 young adults (18–29 years) born <29 weeks of gestation and 95 sex- and age-matched full-term controls. Participants underwent dual-energy X-ray absorptiometry to measure areal BMD and body composition. Generalized estimated equations were used to compare groups adjusting for height Z-score, lean body mass and fat mass.

Results

Adults born preterm were shorter and lighter than full-term controls. Areal BMD was reduced at the lumbar spine, the femoral neck and whole body in the preterm versus full-term group, but after adjustment, areal BMD Z-score was only significantly lower at the femoral neck by −0.3 unit (95% confidence interval −0.6 to −0.0). Low BMD (Z-score ≤ −1 standard deviation) at any site was observed in 53% of adults born preterm versus 28% of full-term controls, but this was not statistically significantly different. We did not identify any neonatal factors associated with lower BMD within the preterm group.

Conclusions

Very preterm birth is associated with lower areal BMD at the femoral neck in young adulthood, even after accounting for body size. Whether this will translate into higher risk of osteoporotic fractures later in life remains unknown.

Neuroimaging perspectives on fetal motor behavior

We are entering a new era of understanding human development with the ability to perform studies at the earliest time points possible. There is a substantial body of evidence to support the concept that early motor behaviour originates from supraspinal motor centres, reflects neurological integrity, and that altered patterns of behaviour precede clinical manifestation of disease. Cine Magnetic Resonance Imaging (cineMRI) has established its value as a novel method to visualise motor behaviour in the human fetus, building on the wealth of knowledge gleaned from ultrasound based studies. This paper presents a state of the art review incorporating findings from human and preclinical models, the insights from which, we propose, can proceed a reconceptualisation of fetal motor behaviour using advanced imaging techniques. Foremost is the need to better understand the role of the intrauterine environment, and its inherent unique set of stimuli that activate sensorimotor pathways and shape early brain development. Finally, an improved model of early motor development, combined with multimodal imaging, will provide a novel source of in utero biomarkers predictive of neurodevelopmental disorders.

Positive Social Interactions in a Lifespan Perspective with a Focus on Opioidergic and Oxytocinergic Systems: Implications for Neuroprotection

In recent years, a growing interest has emerged in the beneficial effects of positive social interactions on health. The present work aims to review animal and human studies linking social interactions and health throughout the lifespan, with a focus on current knowledge of the possible mediating role of opioids and oxytocin. During the prenatal period, a positive social environment contributes to regulating maternal stress response and protecting the fetus from exposure to maternal active glucocorticoids. Throughout development, positive social contact with the caregiver acts as a “hidden regulator” and promotes infant neuroaffective development. Postnatal social neuroprotection interventions involving caregiver–infant physical contact seem to be crucial for rescuing preterm infants at risk for neurodevelopmental disorders. Attachment figures and friendships in adulthood continue to have a protective role for health and brain functioning, counteracting brain aging. In humans, implementation of meditative practices that promote compassionate motivation and prosocial behavior appears beneficial for health in adolescents and adults. Human and animal studies suggest the oxytocinergic and opioidergic systems are important mediators of the effects of social interactions. However, most of the studies focus on a specific phase of life (i.e., adulthood). Future studies should focus on the role of opioids and oxytocin in positive social interactions adopting a lifespan perspective.

Assisted Physical Exercise for Improving Bone Strength in Preterm Infants Less than 35 Weeks Gestation: A Randomized Controlled Trial

Objective

To compare the efficacy of daily assisted physical exercise (starting from one week of postnatal age) on bone strength at 40 weeks of post menstrual age to no intervention in infants born between 27 and 34 weeks of gestation.

Design

Open-label randomized controlled trial.

Setting

Tertiary-care teaching hospital in northern India from 16 May, 2013 to 21 November, 2013.

Participants

50 preterm neonates randomized to Exercise group (n=26) or Control group (n=24).

Intervention

Neonates in Exercise group underwent one session of physical exercise daily from one week of age, which included range-of-motion exercises with gentle compression, flexion and extension of all the extremities with movements at each joint done five times, for a total of 10-15 min. Infants in Control group underwent routine care and were not subjected to any massage or exercise.

Outcome measures

Primary: Bone speed of sound of left tibia measured by quantitative ultrasound at 40 weeks post menstrual age. Secondary: Anthropometry (weight length and head circumference) and biochemical parameters (calcium, phosphorus, alkaline phosphatase) at 40 weeks post menstrual age.

Results

The tibial bone speed of sound was comparable between the two groups [2858 (142) m/s vs. 2791 (122) m/s; mean difference 67.6 m/s; 95% CI -11 to 146 m/s; P=0.38]. There was no difference in anthropometry or biochemical parameters.

Conclusion

Daily assisted physical exercise does not affect the bone strength, anthropometry or biochemical parameters in preterm (27 to 34 weeks) infants.

The Role of Exercise in Prevention and Treatment of Osteopenia of Prematurity: An Update

Premature infants have an increased risk of osteopenia due to limited bone mass accretion in utero and a greater need for bone nutrients. Until recently, most efforts to prevent osteopenia of prematurity focused on nutritional changes. Recent studies indicate that passive range-of-motion exercise of the extremities may lead to beneficial effects on body weight, increased bone mineralization, increased bone formation markers and leptin levels, and attenuation of the natural postnatal decline in bone speed of sound. These results suggest that exercise may play an important role in the prevention and treatment of osteopenia of prematurity. This review summarizes our current knowledge on the role of exercise in the prevention and treatment of osteopenia of prematurity.

Effect of Early Physical Activity Programs on Motor Performance and Neuromuscular Development in Infants Born Preterm: A Randomized Clinical Trial

Introduction: Although the survival rate of infants born preterm has increased, the prevalence of developmental problems and motor disorders among this population of infants remains the same. This study investigated the effect of physical activity programs in and out of water on motor performance and neuromuscular development of infants born preterm and had induced immobility by mechanical ventilation. Methods: This study was carried out in Al-Zahra hospital, Tabriz. 76 premature infants were randomly assigned into four groups. One group received daily passive range of motion to all extremities based on the Moyer-Mileur protocol. Hydrotherapy group received exercises for shoulders and pelvic area in water every other day. A combination group received physical activity programs in and out of water on alternating days. Infants in a containment group were held in a fetal position. Duration of study was two weeks 'from 32 through 33 weeks post menstrual age (PMA). Motor outcomes were measured by the Test of Infant Motor Performance. Neuromuscular developmental was assessed by New Ballard scale and leg recoil and Ankle dorsiflexion items from Dubowitz scale. Data were analyzed using SPSS version 13. Results: TIMP and neuromuscular scores improved in all groups. Motor performance did not differ between groups at 34 weeks PMA. Postural tone of leg recoil was significantly higher in physical activity groups post intervention. Conclusion: Physical activities and containment didn't have different effects on motor performance in infants born preterm. Leg recoil of neuromuscular development items was affected by physical activity programs.

Osteopenia of Prematurity: Does Physical Activity Improve Bone Mineralization in Preterm Infants?

Bone mineralization of preterm infants is significantly less than full-term infants at birth, placing preterm infants at risk for osteopenia of prematurity and other metabolic bone diseases. Advances in nutritional supplementation and standard nursing care alone have been unsuccessful in improving bone mineralization postnatally. Research supports a daily physical activity protocol of passive range of motion and gentle joint compression when combined with adequate nutritional supplementation reduces osteopenia of prematurity. This article provides a systematic review of the current evidence surrounding early physical activity and neonatal massage for the treatment of osteopenia and indicates the need for universal handling protocols in caring for this unique population.

The Effect of Assisted Exercise Frequency on Bone Strength in Very Low Birth Weight Preterm Infants: A Randomized Control Trial

We aimed to assess whether a twice daily assisted exercise interventional program will have a greater effect on bone strength compared to a once daily intervention or no intervention in very low birth weight (VLBW) preterm infants. Thirty-four very VLBW preterm infants (mean BW 1217 ± 55 g and mean gestational age 28.6 ± 1.1 weeks) were randomly assigned into one of three study groups: twice daily interventions (n = 13), a once daily intervention (n = 11), and no intervention (control, n = 10). The intervention was initiated at a mean of 8 ± 2.4 days of life and continued for 4 weeks. It included passive extension and flexion range-of-motion exercise of the upper and lower extremities. Bone strength was measured at enrollment and after 2 and 4 weeks using quantitative ultrasound of tibial bone speed of sound (SOS, Sunlight Omnisense™). At enrollment, the mean bone SOS was comparable between the twice daily interventions, once daily intervention and control groups (2918 ± 78, 2943 ± 119, and 2910 ± 48 m/s, respectively). As expected, the bone SOS declined in all groups during the study period (-23.6 ± 24, -68.8 ± 28, and -115.8 ± 30 m/s, respectively, p < 0.05), with a significantly attenuated decrease in bone strength in the twice daily intervention group (p = 0.03). A twice daily intervention program of assisted range-of-motion exercise attenuates the decrease in bone strength and may decrease the risk of osteopenia and future fractures in VLBW preterm infants.

Lower Newborn Bone Mineral Content Associated With Maternal Use of Tenofovir Disoproxil Fumarate During Pregnancy

BACKGROUND

Fetal bone effects of maternal tenofovir use have not been well studied. We sought to compare whole-body bone mineral content (BMC) of newborns exposed vs not exposed to tenofovir in utero.

METHODS

We enrolled participants from April 2011 to June 2013 at 14 US clinical sites. Singleton infants of women with human immunodeficiency virus (HIV) infection who took tenofovir in late pregnancy (tenofovir-exposed) or no tenofovir during pregnancy (tenofovir-unexposed) were enrolled during late pregnancy or within 72 hours of birth. Infants born before 36 weeks gestation or with confirmed HIV infection were excluded. Whole-body BMC was measured in the first month of life and compared with that of the tenofovir-exposed and tenofovir-unexposed newborns, unadjusted and adjusted for covariates.

RESULTS

Seventy-four tenofovir-exposed and 69 tenofovir-unexposed infants had evaluable BMC measurements. Tenofovir-exposed mothers were more likely to be married (31% vs 22%; P = .04) and to use boosted protease inhibitors (84% vs 62%; P = .004). Tenofovir-exposed newborns did not differ from unexposed newborns on mean gestational age (38.2 vs 38.1 weeks) or mean length (-0.41 vs -0.18) or weight (-0.71 vs -0.48) Z-scores. The mean (standard deviation) BMC of tenofovir-exposed infants was 12% lower than for unexposed infants (56.0 [11.8] vs 63.8 [16.6] g; P = .002). The adjusted mean bone mineral content was 5.3 g lower (95% confidence interval, -9.5, -1.2; P = .013) in the tenofovir-exposed infants.

CONCLUSIONS

Maternal tenofovir use is associated with significantly lower neonatal BMC. The duration and clinical significance of this finding should be evaluated in longitudinal studies.

CLINICAL TRIALS REGISTRATION

ClinicalTrials.gov NCT01310023.

Time since onset of walking predicts tibial bone strength in early childhood

Bone strength in adulthood is known to be affected by health at birth and early childhood. Habitual bone loading is a primary determinant of bone strength in later childhood and adulthood. However, the effects of physical activity in early childhood (e.g. crawling, standing and walking) on bone strength are unknown. Fifty-three children (twenty-seven males) were included in a longitudinal study in their early infancy. Shortly after birth (0.3±0.3months), details of mass and height were obtained along with a pQCT scan at 20% distal-proximal tibia length. At 14.8±0.5months of age the same data were collected, along with details of age at onset of standing, crawling, supported and unsupported walking. Time since onset of walking unsupported was associated with greater bone mass, cortical bone area, pericortical circumference and polar moment of inertia of both total and cortical bone (all P<0.05). There were no significant associations between other physical activity timepoints and bone measures. Age at onset of walking was not significantly related to mass, length or bone measures at birth. The results suggest that time since attainment of independent walking - representing exposure of the tibia to the large reaction and muscular forces associated with locomotion - is a primary determinant of bone strength in early childhood. This finding raises the possible opportunity of physical activity interventions at young age in paediatric populations associated with low childhood bone strength and late walking (e.g. low birth weight, cerebral palsy and Down's Syndrome, etc.).

Physical activity programs for promoting bone mineralization and growth in preterm infants

BACKGROUND

Lack of physical stimulation may contribute to metabolic bone disease of preterm infants, resulting in poor bone mineralization and growth. Physical activity programs combined with adequate nutrition might help to promote bone mineralization and growth.

OBJECTIVES

The primary objective was to assess whether physical activity programs in preterm infants improve bone mineralization and growth and reduce the risk of fracture.The secondary objectives included other potential benefits in terms of length of hospital stay, skeletal deformities and neurodevelopmental outcomes, and adverse events.Subgroup analysis:• Given that the smallest infants are most vulnerable for developing osteopenia (Bishop 1999), a subgroup analysis was planned for infants with birth weight < 1000 g.• Calcium and phosphorus intake may affect an infant's ability to increase bone mineral content (Kuschel 2004). Therefore, an additional subgroup analysis was planned for infants receiving different amounts of calcium and phosphorus, along with full enteral feeds as follows. ∘ Below 100 mg/60 mg calcium/phosphorus or equal to/above 100 mg/60 mg calcium/phosphorus per 100 mL milk. ∘ Supplementation of calcium without phosphorus. ∘ Supplementation of phosphorus without calcium.

SEARCH METHODS

The standard search strategy of the Cochrane Neonatal Review Group (CNRG) was used. The search included the Cochrane Central Register of Controlled Trials (CENTRAL) (2012, Issue 9), MEDLINE, EMBASE, CINAHL (1966 to March 2013), and cross-references, as well as handsearching of abstracts of the Society for Pediatric Research and the International Journal of Sports Medicine.

SELECTION CRITERIA

Randomized and quasi-randomized controlled trials comparing physical activity programs (extension and flexion, range-of-motion exercises) versus no organized physical activity programs in preterm infants.

DATA COLLECTION AND ANALYSIS

Data collection, study selection, and data analysis were performed according to the methods of the CNRG.

MAIN RESULTS

Eleven trials enrolling 324 preterm infants (gestational age 26 to 34 weeks) were included in this review. All were small (N = 16 to 50) single-center studies that evaluated daily physical activity for three and one-half to eight weeks during initial hospitalization. Methodological quality and reporting of included trials were variable.Four trials demonstrated moderate short-term benefits of physical activity for bone mineralization at completion of the physical activity program. The only trial assessing long-term effects on bone mineralization showed no effect of physical activity administered during initial hospitalization on bone mineralization at 12 months corrected age. Meta-analysis from four trials demonstrated a positive effect of physical activity on daily weight gain (weighted mean difference (WMD) 2.21 g/kg/d, 95% confidence interval (CI) 1.23 to 3.19). Data from four trials showed a positive effect on linear growth (WMD 0.12 cm/wk, 95% CI 0.01 to 0.24) but not on head growth (WMD -0.03 cm/wk, 95% CI -0.14 to 0.08) during the study period. Only one trial reported on fractures (this outcome did not occur in intervention and control groups) and complications of preterm birth (no significant differences between intervention and control groups). None of the trials assessed other outcomes relevant to this review.

AUTHORS' CONCLUSIONS

Some evidence suggests that physical activity programs might promote short-term weight gain and bone mineralization in preterm infants. Data are inadequate to allow assessment of harm or long-term effects. Current evidence does not support the routine use of physical activity programs in preterm infants. Further trials incorporating infants with a high baseline risk of osteopenia are required. These trials should address adverse events, long-term outcomes, and the effects of nutritional intake (calories, protein, calcium, phosphorus).

Preterm infant weight gain is increased by massage therapy and exercise via different underlying mechanisms

OBJECTIVE

To compare the effects of massage therapy (moderate pressure stroking) and exercise (flexion and extension of limbs) on preterm infants' weight gain and to explore potential underlying mechanisms for those effects.

METHODS

Weight gain and parasympathetic nervous system activity were assessed in 30 preterm infants randomly assigned to a massage therapy group or to an exercise group. Infants received 10min of moderate pressure massage or passive flexion and extension of the limbs 3 times per day for 5days, and EKGs were collected during the first session to assess vagal activity.

RESULTS

Both massage and exercise led to increased weight gain. However, while exercise was associated with increased calorie consumption, massage was related to increased vagal activity.

CONCLUSION

Taken together, these findings suggest that massage and exercise lead to increased preterm infant weight gain via different underlying mechanisms.

Assessment of bone health in preterm infants through quantitative ultrasound and biochemical markers

OBJECTIVE

To assess bone status in preterm infants with quantitative ultrasound and to search for biochemical markers of bone health.

METHODS

Metacarpus bone transmission time (mcBTT) was prospectively performed during hospitalization, together with biochemical and clinical outcomes analysis.

RESULTS

154 patients were studied. At 3rd week of life mcBTT positively correlated with serum phosphate. Urinary excretion of calcium and phosphate were assessed in a subgroup of 55 patients: on day 21 mcBTT positively correlated with phosphaturia, negatively with calciuria. Gestational age (GA), weight and length at 3rd week and at 36 weeks of GA correlated positively with mcBTT. We found negative correlation between mcBTT at 3rd week and days of parenteral nutrition, mechanical ventilation period and days to reach 1800 g.

CONCLUSIONS

Serum phosphate, phosphaturia and calciuria correlate most with mcBTT. Further studies are necessary to verify the possible influence of early bone status on future bone health.

Thai traditional massage increases biochemical markers of bone formation in postmenopausal women: a randomized crossover trial

Background

The effect of massage therapy on bone metabolism in adults has only scarcely been explored. In a randomized crossover trial, we investigated the skeletal effect of Thai traditional massage by examining the changes in biochemical markers of bone turnover.

Methods

Forty-eight postmenopausal women participated in the study. All volunteers were randomized to a 2-hour session of Thai traditional massage twice a week for 4 weeks and a 4-week control period after a 2-week washout, or vice versa. Twenty-one subjects were allocated to receiving Thai traditional massage first, followed by the control period, while 27 were initially allocated to the control period.

Results

Serum P1NP increased significantly after Thai traditional massage (P <0.01), while there was no change in serum osteocalcin or CTX. During the control period, there was no significant change in P1NP, osteocalcin or CTX compared to baseline. When age and height were taken into account, P1NP in postmenopausal women whose ages were in the middle and higher tertiles and whose heights were in the lower and middle tertiles (n = 22) had a 14.8 ± 3.3% increase in P1NP after massage (P <0.001), while no change in P1NP was found in the rest of the women (n = 26).

Conclusions

Thai traditional massage results in an increase in bone formation as assessed by serum P1NP, particularly in postmenopausal women who are older and have a smaller body build. Future studies with larger samples and additional design features are warranted.

Trial registration

ClinicalTrials.gov : NCT01627028

Fractures in hospitalized children

Hospitalized children have multiple risk factors for fragility fractures, related to disease pathophysiology, treatments, nutritional status and immobilization. Recognition and treatment of these risk factors are important to prevent morbidity associated with fractures and to promote current and future bone health. Many knowledge gaps remain regarding the ideal nutrition, physical activity, and medication regimens needed to optimize bone health and reduce the risk of fractures over the life course. This article reviews the pathogenesis, risk factors, treatment and prevention strategies for fractures in hospitalized infants and children.

Application of the NICU practice guidelines to treat an infant in a level III NICU

PURPOSE

The purpose of this case report was to determine how current physical therapy (PT) practice in the neonatal intensive care unit (NICU), with 1 infant, adhered to the neonatal PT decision-making framework that was developed as part of the NICU practice guidelines for clinical care.

SUMMARY OF KEY POINTS

Most PT interventions implemented in this NICU were supported by the algorithm, with some steps more readily implemented than others.

CONCLUSIONS

This case report highlights the utility of the NICU clinical decision-making algorithm for not only assisting with developing an evidence-based PT plan of care for an infant at high risk but also its usefulness in revealing NICU programmatic and policy strengths and areas for improvement.

RECOMMENDATIONS FOR CLINICAL PRACTICE

The NICU developmental and therapeutic teams are encouraged to conduct similar endeavors to assess the quality of PT care in their NICUs.

Tactile/kinesthetic stimulation (TKS) increases tibial speed of sound and urinary osteocalcin (U-MidOC and unOC) in premature infants (29-32weeks PMA)

Preterm delivery (<37 weeks post-menstrual age) is associated with suboptimal bone mass. We hypothesized that tactile/kinesthetic stimulation (TKS), a form of infant massage that incorporates kinesthetic movement, would increase bone strength and markers of bone accretion in preterm infants. Preterm, AGA infants (29-32 weeks) were randomly assigned to TKS (N=20) or Control (N=20). Twice daily TKS was provided 6 days per week for 2 weeks. Control infants received the same care without TKS treatment. Treatment was masked to parents, health care providers, and study personnel. Baseline and week two measures were collected for tibial speed of sound (tSOS, m/sec), a surrogate for bone strength, by quantitative ultrasound (Sunlight8000) and urine markers of bone metabolism, pyridinium crosslinks and osteocalcin (U-MidOC and unOC). Infant characteristics at birth and study entry as well as energy/nutrient intake were similar between TKS and Control. TKS intervention attenuated the decrease in tSOS observed in Control infants (p<0.05). Urinary pyridinium crosslinks decreased over time in both TKS and CTL (p<0.005). TKS infants experienced greater increases in urinary osteocalcin (U-MidOC, p<0.001 and unOC, p<0.05). We conclude that TKS improves bone strength in premature infants by attenuating the decrease that normally follows preterm birth. Further, biomarkers of bone metabolism suggest a modification in bone turnover in TKS infants in favor of bone accretion. Taken together, we speculate that TKS improves bone mineralization.

A Haptic Simulator for Training the Application of Range of Motion Exercise to Premature Infants

The range of motion exercise is an experimental therapy for improving bone and muscle growth in premature infants but little is known about the magnitude of pressures that must be applied to the limbs during this exercise to elicit a physiological benefit and novice caregivers currently must rely on subjective instruction to learn to apply appropriate pressures. The goal of this study was to quantify the pressures applied by experienced caregivers during application of this exercise and to create a haptic simulator that could be used to train novice caregivers such as parents to apply the same pressures. We quantified the pressure applied by two neonatal intensive care nurses (“experts”) to the wrists of nine newborn, premature infants of varying gestational ages using an infant blood pressure cuff modified to act as a finger pressure sensor. The experts applied statistically significant different pressures depending on gestational age but did not differ significantly between themselves in the pressure they applied. We then created a robotic simulator of the premature infant wrist and programmed it to respond with the measured pressure-angle properties of the actual infants’ wrists. The novice adult participants (n=19) used the simulator to learn to apply target pressures for simulated wrists that corresponded to three different gestational ages. Training with the simulator for 30 min allowed the participants to learn to apply pressures significantly more like those of the experts. The performance improvement persisted at a retention test several days later. These results quantify for the first time the pressures applied during assisted exercise, include novel observations about joint flexibility and maturation early in life and suggest a strategy for teaching exercise intervention teams to provide assisted exercise within a more reproducible range using haptic simulation technology.