Serial serum alkaline phosphatase as an early biomarker for osteopenia of prematurity

A case report of osteopenia of prematurity

The girl neonate with 1500 g, was transferred to the neonatal intensive care unit due to tachypnea and prematurity. She received supportive and therapeutic care in the course of hospitalization. Due to the high level of alkaline phosphatase in the examinations and x-rays of the wrist, premature osteopenia was diagnosed and she was treated with high doses of calcium and phosphorus. Alkaline phosphatase was measured weekly in the course of treatment, with its downward trend indicating an appropriate response to treatment. Although osteoporosis is a common and recurrent disease in premature neonate, but it can be decrease with preventing factors that lead to premature infants and by providing necessary screening and proper timely treatment with nutritional supplements and prevented the progress of the disease.

Analysis of clinical risk factors for metabolic bone disease of prematurity

Objective

To analyze clinical data related to preterm infants and identify risk factors for metabolic bone disease of prematurity (MBDP).

Methods

This study involved 856 newborns with a gestational age of less than 37 weeks or a weight of less than 1,500g at the Second Hospital of Jilin University. Multifactorial analysis was performed using logistic regression models to explore the risk factors for MBDP. Linear regression was used to investigate the factors affecting the time of alkaline phosphatase (ALP) exceedance and the peak value of ALP in the MBDP group.

Results

In the MBDP group, ALP excesses occurred in preterm infants at an average of 39.33 days after birth, and the mean value of peak ALP was 691.41 IU/L. Parenteral nutrition and the application of assisted ventilation were independent risk factors for MBDP, with ORs of 1.02 and 1.03 respectively. Gestational age was found to be a protective factor for earlier time of onset of ALP exceedance (β = 2.24,) and the increase in the peak value of ALP (β = -16.30).

Conclusion

Parenteral nutrition and the application of assisted ventilation are independent risk factors for MBDP. Gestational age is a major factor influencing the time of onset of ALP exceedance and the peak value of ALP in infants with MBDP.

Continuous versus intermittent bolus infusion of calcium in preterm infants receiving total parenteral nutrition: a randomized blind clinical trial

BACKGROUND

Premature neonates need adequate nutritional support to provide sufficient essential nutrients for optimal growth. Calcium (Ca) is one of the important nutrients in parental nutrition support of premature infants. This study aimed to compare the effect of continuous and intermittent bolus infusion of Ca on the incidence of metabolic bone disease (MBD) in preterm infants.

METHODS

This randomized double-blind clinical trial was conducted on ninety preterm infants in the NICU of Al-Zahra Hospital in Tabriz, Iran. The preterm infants were randomly allocated to either a continuous infusion group (received 4-5 ml/kg/day of Ca gluconate 10% by PN solution in a 24-h period) or an intermittent bolus administration group (received 1-2 ml/kg/day Ca gluconate 10% three to four times per day). Serial serum levels of Ca, phosphorous, alkaline phosphatase (ALP), vitamin D and parathyroid hormone (PTH) were assessed on the 7th day, 30th day and 45th day of life.

RESULTS

A total of 78 infants completed the study. The serum ALP level on the 45th day after birth was 753.28 ± 304.59 IU/L and 988.2 ± 341.3 IU/L in the continuous infusion and intermittent bolus administration groups, respectively (P < 0.05). MBD in preterm infants with ALP levels above 900 IU/L on the 45th day of life was significantly lower in the continuous infusion group than in the intermittent bolus administration group (p < 0.05). The mean serum levels of calcium, phosphorus, vitamin D and PTH in 45-day-old infants were not significantly different between the two groups.

CONCLUSION

The MBD in preterm infants who received continuous infusion of Ca was lower than that in preterm infants who received intermittent bolus administration of Ca.

TRIAL REGISTRATION

The Iranian Registry of Clinical Trials ( http://www.irct.ir ) with the identification No. IRCT20210913052466N1.

Calcium and Phosphorus: All You Need to Know but Were Afraid to Ask

Inadequate intake of calcium and phosphorus during the perinatal period can result in metabolic bone disease (MBD), characterized by decreased bone mass, altered bone mineralization, and increased risk for fractures. Preterm neonates have higher risk of developing MBD. Treating MBD involves ensuring adequate calcium and phosphorus intake, early fortification, and vitamin D supplementation. Health care providers should closely monitor nutrient intake, postnatal growth, and screening of preterm neonates at risk for MBD. This review summarizes the critical roles of calcium and phosphorus in regulating bone physiology, how they regulate bone formation and resorption, and their influence on overall bone health.

Sodium Glycerophosphate Use in Parenteral Nutrition Improves Mineral Metabolism in Extremely Low Birth Weight Infants

OBJECTIVE

To evaluate the clinical effect of sodium glycerophosphate (NaGP) in parenteral nutrition solutions on mineral metabolism in extremely low birth weight (ELBW) infants.

STUDY DESIGN

NaGP was introduced for use in place of potassium phosphate (K₃PO₄) in January 2018; this retrospective cohort study included 95 ELBW infants treated with K₃PO₄ between January 2015 and December 2017 and 77 infants treated with NaGP between August 2018 and January 2021. Mineral intake over the first 14 days; changes in serum calcium, phosphorus, sodium, and alkaline phosphatase (ALP) levels over the first 1-3 months; and the rates of electrolyte imbalance and clinical morbidity were compared. High-risk infants who had nil per os (NPO) status for >14 days and prolonged parenteral nutrition exposure were further analyzed as a subgroup.

RESULTS

The use of NaGP instead of K₃PO₄ significantly increased Ca and P intake, but intakes remained below the recommended range (Ca, 64-140 mg/kg/day; P, 50-108 mg/kg/day). Compared with levels in the K₃PO₄ group, the NaGP group had significantly higher serum Ca and P levels after day 14 and lower ALP levels after day 56. In the subgroup analysis, the NaGP group had significantly lower incidences of hypophosphatemia, hyponatremia, bronchopulmonary dysplasia, and ALP >500 IU/L.

CONCLUSIONS

Although the administration of NaGP instead of K₃PO₄ in parenteral nutrition regimens still did not provide adequate Ca and P intake for ELBW infants, higher intake significantly improved serum Ca and P levels, especially in ELBW infants with prolonged parenteral nutrition exposure.

Effectiveness and safety of early versus late caffeine therapy in managing apnoea of prematurity among preterm infants: a retrospective cohort study

BACKGROUND

Early administration of intravenous (IV) caffeine (initiation within 2 days of life) is an effective treatment strategy for the management of apnoea of prematurity among infants. However, the safety and effectiveness of early administration of oral caffeine treatment is not be fully established.

AIM

We aimed to compare the effectiveness and safety of early versus late caffeine therapy on preterm infants' clinical outcomes.

METHOD

A retrospective matched cohort study was conducted using data of patients admitted to neonatal intensive care units of two tertiary care hospitals between January 2016 and December 2018. The clinical outcomes and mortality risk between early caffeine (initiation within 2 days of life) and late caffeine (initiation ≥ 3 days of life) were compared.

RESULTS

Ninety-five pairs matched based on gestational age were included in the study. Compared to late initiation, preterm infants with early caffeine therapy had: a shorter duration of non-invasive mechanical ventilation (median 5 days vs. 12 days; p < 0.001); shorter length of hospital stay (median 26 days vs. 44 days; p  < 0.001); shorter duration to achieve full enteral feeding (median 5 days vs. 11 days; p < 0.001); and lower frequency of bronchopulmonary dysplasia (BPD) (4.5% vs. 12.9%; p = 0.045). They also had a reduced risk of osteopenia of prematurity (OP) (OR 0.209; 95% CI 0.085-0.509; p = 0.001).

CONCLUSION

Early oral caffeine therapy can potentially improve respiratory outcomes among infants with apnoea of prematurity. However, an increase in mortality associated with early caffeine therapy requires further investigation.

Relationship of caffeine regimen with osteopenia of prematurity in preterm neonates: a cohort retrospective study

BACKGROUND

Caffeine is a routinely prescribed pharmacological active compound in neonatal intensive care units (NICU) for treating apnea of prematurity (AOP), which also decreases the risk of bronchopulmonary dysplasia and cerebral palsy in neonates. Caffeine-induced excessive calcium loss can promote the development of metabolic bone disease (MBD) in preterm neonates. This study aimed to evaluate the effect of the caffeine regimen on the development of osteopenia of prematurity (OOP), using serum alkaline phosphatase (serum-ALP) concentrations as a surrogate marker at the 4^th week of life.

METHODS

This retrospective cohort study was conducted including neonates of < 32 weeks gestational age (GA) and birth weight < 1500 g, admitted to NICU from April-2017 to December-2018 and received caffeine therapy till 28 days of life for AOP. Based on serum-ALP levels, formed the high and low-ALP groups. Neonatal characteristics, caffeine regimen, risk factors for OOP, including duration of parenteral nutrition (PN), exposure to medicines associated with MBD, and intake of essential vitamins and minerals, were compared in both groups. Predictors of OOP were analyzed through logistic regression.

RESULTS

From the total of 268 participants, 52 (19%) developed OOP, mostly female (61.5%). In the high ALP group, the serum-ALP levels were significantly higher than in the low-ALP group (725.0 ± 143.8 vs 273.6 ± 55.0 units/L, p < 0.001). The high-ALP group received significantly (p < 0.001) higher daily and cumulative caffeine doses and were associated with a higher likelihood of developing OOP in this study cohort [cumulative dose (mg) (AOR = 1.082 95% CI 1.011 to 1.157) and daily dose (mg/kg/day) (AOR = 2.892 95% CI 1.392 to 6.007)]. Smaller GA was found directly related to OOP. Among the other medical risk factors, phosphorus intake was significantly low in the high-ALP group. No, significant relationship between duration of PN and use of steroids and diuretics, and intake of vitamins and minerals were identified.

CONCLUSION

The daily and cumulative doses of caffeine and smaller GA are associated with the development of OOP in this study cohort. Clinical randomized control studies are needed to validate the outcomes and determine the range of safest and most effective caffeine doses for treating AOP in preterm neonates.

Alkaline Phosphatase Electrochemical Micro-Sensor Based on 3D Graphene Networks for the Monitoring of Osteoblast Activity

Alkaline phosphatase (ALP) is a significant biomarker that indicates osteoblast activity and skeletal growth. Efficient ALP detection methods are essential in drug development and clinical diagnosis. In this work, we developed an in-situ synthesized three-dimensional graphene networks (3DGNs)-based electrochemical sensor to determine ALP activity. The sensor employs an ALP enzymatic conversion of non-electroactive substrate to electroactive product and presents the ALP activity as an electrochemical signal. With 3DGNs as the catalyst and signal amplifier, a sample consumption of 5 μL and an incubation time of 2 min are enough for the sensor to detect a wide ALP activity range from 10 to 10,000 U/L, with a limit of detection of 5.70 U/L. This facile fabricated sensor provides a quick response, cost-effective and non-destructive approach for monitoring living adherent osteoblast cell activity and holds promise for ALP quantification in other biological systems and clinical samples.

Parenteral Nutrition

Prematurity and other complications at birth are nutritional emergencies. Parenteral nutrition is a bridge to enteral nutrition for a few days or months, and sometimes the sole source of nutrition for life. Parenteral nutrition regimens are constructed to provide adequate and balanced energy, macronutrients, and micronutrients to support growth and prevent deficiencies. Neonatal parenteral nutrition regimens are complicated by periodic shortages of essential products, compatibility challenges, and contaminants. Newborns benefit from serial growth assessments, monitoring of biochemical status, nutrition-focused physical examinations, and management by a multidisciplinary team to ensure adequacy of parenteral nutrition and promote best outcomes.

When AIE meets enzymes

Applications of AIEgens in biosensing, disease diagnosis, and drug release.

Dynamic trend in alkaline phosphatase activity in infants aged 0-12 months revealed by an indirect approach

OBJECTIVE

Alkaline phosphatase (ALP) is a ubiquitous enzyme in humans that can be used for diagnosing childhood diseases. Infants have the highest rapid growth rate and are susceptible to metabolic bone diseases. In infants, ALP activities exhibit significant month-wise variations, and authoritative standards are lacking. The present study aimed to provide a reference for the diagnosis of diseases related to abnormal ALP activities in infants.

METHODS

This study included 24,618 samples collected from infants aged 0-12 months from three medical centers in Chongqing, China. Samples of infants diagnosed with diseases that may affect ALP activity have been exclude. ALP activity was analyzed using an automatic biochemical analyzer. A percentile curve for ALP activity in male and female infants was constructed using MATLAB, and the skewness-median-coefficient of variation method was employed for curve fitting.

RESULTS

ALP activity in male and female infants peaked at 0-4 months; the peak appeared at 1-2 months and declined gradually thereafter. After 4-5 months of age, the ALP activities declined further, with the lowest values observed at 11-12 months of age. A comparison between the data from this study and a those from a published German study indicates that Chinese infants exhibited peak ALP activity later and subsequent decline greater than German infants.

CONCLUSIONS

A percentile curve was constructed for month-wise ALP activity in male and female infants, which could provide a reference for diagnosing diseases related to abnormal ALP activity in infants.

Enzymatically Forming Intranuclear Peptide Assemblies for Selectively Killing Human Induced Pluripotent Stem Cells

Tumorigenic risk of undifferentiated human induced pluripotent stem cells (iPSCs), being a major obstacle for clinical application of iPSCs, requires novel approaches for selectively eliminating undifferentiated iPSCs. Here, we show that an l-phosphopentapeptide, upon the dephosphorylation catalyzed by alkaline phosphatase (ALP) overexpressed by iPSCs, rapidly forms intranuclear peptide assemblies made of α-helices to selectively kill iPSCs. The phosphopentapeptide, consisting of four l-leucine residues and a C-terminal l-phosphotyrosine, self-assembles to form micelles/nanoparticles, which transform into peptide nanofibers/nanoribbons after enzymatic dephosphorylation removes the phosphate group from the l-phosphotyrosine. The concentration of ALP and incubation time dictates the morphology of the peptide assemblies. Circular dichroism and FTIR indicate that the l-pentapeptide in the assemblies contains a mixture of an α-helix and aggregated strands. Incubating the l-phosphopentapeptide with human iPSCs results in rapid killing of the iPSCs (=<2 h) due to the significant accumulation of the peptide assemblies in the nuclei of iPSCs. The phosphopentapeptide is innocuous to normal cells (e.g., HEK293 and hematopoietic progenitor cell (HPC)) because normal cells hardly overexpress ALP. Inhibiting ALP, mutating the l-phosphotyrosine from the C-terminal to the middle of the phosphopentapeptides, or replacing l-leucine to d-leucine in the phosphopentapeptide abolishes the intranuclear assemblies of the pentapeptides. Treating the l-phosphopentapeptide with cell lysate of normal cells (e.g., HS-5) confirms the proteolysis of the l-pentapeptide. This work, as the first case of intranuclear assemblies of peptides, not only illustrates the application of enzymatic noncovalent synthesis for selectively targeting nuclei of cells but also may lead to a new way to eliminate other pathological cells that express a high level of certain enzymes.

Expert consensus on clinical management of metabolic bone disease of prematurity (2021)

Metabolic bone disease of prematurity (MBDP) is a systemic bone disease with a reduction in bone mineral content due to disorder of calcium and phosphorus metabolism. There is still a lack of in-depth research and systematic understanding of MBDP in China, and there are many irregularities in clinical management of this disease. Based on relevant studies in China and overseas, Grading of Recommendations Assessment, Development and Evaluation was used to develop the expert consensus on the clinical management of MBDP, which provides recommendations from the following five aspects: high-risk factors, screening/diagnosis, prevention, treatment, and post-discharge follow-up of MBDP, so as to provide relevant practitioners with recommendations on the clinical management of MBDP to reduce the incidence rate of MBDP and improve its short- and long-term prognosis.

The incidence of osteopenia of prematurity in preterm infants without phosphate supplementation: A prospective, observational study

To meet their requirements for bone mineralization, it is recommended that preterm infants receive nutritional support containing calcium and phosphate. There are no clear data on the incidence of osteopenia of prematurity (OFP) in preterm infants without phosphate supplementation.This study aimed to investigate the incidence of OFP in preterm infants without phosphate supplementation and its relationship with the duration of parenteral nutrition (PN).This was a prospective and observational study.This study included 30 infants aged <32 gestational weeks and weighed <1500 g at birth. All infants received PN according to a standard protocol, beginning on day 1 with calcium, without phosphate. Starting from the first day of life, all infants received human milk without fortifiers. Oral vitamin D (400 IU/d) was administered when enteral nutrition reached 100 mL/kg/d.The diagnosis of OFP was based on radiographs that were taken of both wrists. Serum alkaline phosphatase (ALP) was measured 3 times: at the start of PN (ALP 1), at the end of PN (ALP 2), and at discharge or the expected due date (ALP 3). Radiographs were obtained on the same day as ALP 3. The duration of PN was analyzed in the presence of OFP using receiver operating characteristic curve analysis.Among the 30 infants, 13 (43%) were diagnosed with OFP. The duration of PN was significantly longer in the OFP group than in the group without OFP (16 vs 12 days; P < .05). The provision of PN for >15 days significantly increased the risk of OFP (odds ratio, 5.40; 95% confidence interval, 1.12-26.04; P = .035).We found a high incidence of OFP in preterm infants without phosphate supplementation. An association was found between the duration of PN and the incidence of OFP. Further research is needed to prevent the development of osteopenia in preterm infants.

Update on Calcium and Phosphorus Requirements of Preterm Infants and Recommendations for Enteral Mineral Intake

Background: With current Ca and P recommendations for enteral nutrition, preterm infants, especially VLBW, fail to achieve a bone mineral content (BMC) equivalent to term infants. During the first 3 years, most notably in light at term equivalent age (<−2 Z score) VLBW infants’ BMC does not catch up. In adults born preterm with VLBW or SGA, lower adult bone mass, lower peak bone mass, and higher frequency of osteopenia/osteoporosis have been found, implying an increased risk for future bone fractures. The aim of the present narrative review was to provide recommendation for enteral mineral intake for improving bone mineral accretion. Methods: Current preterm infant mineral recommendations together with fetal and preterm infant physiology of mineral accretion were reviewed to provide recommendations for improving bone mineral accretion. Results: Current Ca and P recommendations systematically underestimate the needs, especially for Ca. Conclusion: Higher enteral fortifier/formula mineral content or individual supplementation is required. Higher general mineral intake (especially Ca) will most likely improve bone mineralization in preterm infants and possibly the long-term bone health. However, the nephrocalcinosis risk may increase in infants with high Ca absorption. Therefore, individual additional enteral Ca and/or P supplementations are recommended to improve current fortifier/formula mineral intake.

Associated neonatal and maternal factors of osteopenia of prematurity in low resource setting: A cross-sectional study

Objective

Determining neonatal and maternal factors that are associated with the incidence of OFP.

Methods

This study employed a cross-sectional design, in which the participants were identified for clinical variables (sex, gestational age, birth weight, etc.), neonatal morbidity (sepsis, necrotizing enterocolitis (NEC), etc.), and maternal risk factors (premature rupture of membranes, preeclampsia, etc.). The data were analyzed using Chi-square test, independent t-test, and logistic regression test with p < 0.05.

Results

The birth weight ranged from 800 to 1495 g (1219 ± 225 g), of which 5 newborns (17%) were <1000 g. The gestational age ranged from 27 to 32 weeks, with a mean of 29 ± 1.5 weeks. The signs of OFP were observed in 13 (43%) infants, of which 2 (15%) OFP infants had a birth weight <1000 g. There was significant difference in parenteral nutrition duration (p = 0.018), onset of vitamin D supplementation (p = 0.019), and ALP level (p = 0.012) of infants between the OFP group and the non-OFP group. The variables associated with the incidence of OFP were parenteral nutrition duration >15 days (OR = 5.4; 95% CI 1.120-26.044; p = 0.036), ALP level >500 U/L (OR = 2.889; 95% CI 1.703-4.900; p = 0.014), and PROM (OR = 5.4; 95% CI 1.039-28.533; p = 0.045).

Conclusion

The lack of phosphate intake, prolonged parenteral nutrition, ALP level >500 U/L, onset of vitamin D supplementation, and premature rupture of membranes are associated with the incidence of OFP.

Screening of Serum Alkaline Phosphatase and Phosphate Helps Early Detection of Metabolic Bone Disease in Extremely Low Birth Weight Infants

Background: Extremely low birth weight (ELBW, <1,000 g) infants have a high risk of metabolic bone disease (MBD). Because of the late appearance of radiological signs, diagnosis of MBD in ELBW infants might be delayed, and its prevalence underestimated in this group of patients. This study adopted serial screening of serum alkaline phosphatase (ALP) and phosphate (P) of ELBW infants to determine whether such screening is helpful for the early detection of MBD. Materials and Methods: We performed a retrospective study of preterm infants with a gestational age ≤ 31 weeks and birth weight <1,000 g. MBD was absent (ALP ≤500 IU/L), mild (ALP >500 IU/L, P ≥4.5 mg/dL), and severe (ALP >500 IU/L, P <4.5 mg/dL); MBD was divided into early MBD (≤4 weeks after birth) and late MBD (>4 weeks after birth) according to the time of onset. Results: A total of 142 ELBW infants were included, with a median gestational age of 28.1 (26.5-29.7) weeks and a median birth weight of 875 (818-950) g. Seventy-three cases of MBD were diagnosed, and the total prevalence was 51.4% (mild MBD, 10.6%; and severe MBD, 40.8%). Male sex, breastfeeding, and sepsis would increase the risk of severe MBD. Most MBD in ELBW infants occurred at 3-4 weeks after birth. Sixty-two percent (45/73) of infants were diagnosed as having early MBD, which are diagnosed earlier than late MBD [24 (21-26) vs. 39 (36-41), t = -7.161; P < 0.001]. Male sex [odds ratio (OR), 2.86; 95% confidence interval (CI), 1.07-7.64; P = 0.036], initial high ALP levels (OR, 1.02; 95% CI, 1.01-1.03; P < 0.001), and breastfeeding (OR, 5.97; 95% CI, 1.01-25.12; P = 0.049) are independent risk factors for the development of early MBD. Conclusion: The risk of MBD among ELBW infants is very high. Most cases occurred early and were severe. Male sex, initial high ALP levels, and breastfeeding are closely related to the increased risk of early MBD. Serial screening of serum ALP and P helps early detection of MBD; it is recommended to start biochemical screening for ELBW infants 2 weeks after birth and monitor their biochemical markers weekly.

Modified Serum ALP Values and Timing of Apparition of Knee Epiphyseal Ossification Centers in Preterm Infants with Cholestasis and Risk of Concomitant Metabolic Bone Disease of Prematurity

The usefulness of serum alkaline phosphatase (ALP) and phosphorous in screening and monitoring of metabolic bone disease of prematurity (MBDP) still has some limitations, especially in preterm infants with concomitant conditions such as cholestasis. We aimed to assess a modification of serum ALP (M-ALP) as a biomarker for MBDP in preterm infants, and the use of ultrasound monitoring for the apparition of knee ossification centers as marker of bone mineralization. Biochemical and clinical registers were taken from 94 preterm newborns <32 weeks. A significant correlation existed between serum ALP and direct bilirubin (DB), expressed by the regression equation: M-ALP (IU/L) = 302.1 + 96.9 (DB (mg/dL)). The ratio ALP/M-ALP > 1 was demonstrated to be more specific (87.5%) in the diagnosis of MBDP than the cut-off value of serum ALP > 500 IU/L (62.5%). ALP/M-ALP > 1 showed 100% sensitivity and specificity for the diagnosis of MBDP, and a good correlation with specific bone ALP (B-ALP). Patients with the knee nucleus by post-menstrual week 37 had lower B-ALP compared to patients with no nucleus, and no patients with MBDP presented the nucleus by the 40th week. In the absence of reliable specific B-ALP, reinterpreting serum ALP values by M-ALP plus monitoring of knee ossification centers contribute to better management of MBDP in preterm infants with cholestasis.

Metabolic Bone Disease of Prematurity: Risk Factors and Associated Short-Term Outcomes

Despite the importance of early recognition of metabolic bone disease (MBD) of prematurity, there is still significant variability in screening practices across institutions. We conducted an observational study of infants born at ≤32 weeks of gestation with a birth weight of ≤1500 g (n = 218) to identify clinical factors associated with biochemical indicators of MBD. Bone mineral status was assessed by measuring alkaline phosphatase and phosphate levels between weeks 3 and 5 of life. Two comparisons were performed after classifying infants as either MBD (cases) or non-MBD (controls), and as either high or low risk for MBD, as determined based on the results of MBD screening. In total, 27 infants (12.3%) were classified as cases and 96 (44%) as high-risk. Compared with controls, MBD infants had a significantly lower gestational age and birth weight, and a longer duration of parenteral nutrition and hospital stay. Respiratory outcomes were significantly poorer in high- versus low-risk infants. Multivariate logistic regression showed that birth weight was the only independent risk factor for MBD (odds ratio [OR]/100 g, 0.811; confidence interval [CI95%], 0.656-0.992; p = 0.045) and that birth weight (OR/100 g, 0.853; CI95%, 0.731-0.991; p = 0.039) and red blood cell transfusion (OR, 2.661; CI95%, 1.308-5.467; p = 0.007) were independent risk factors for high risk of MBD. Our findings provide evidence of risk factors for MBD that could help clinicians to individualize perinatal management. The association of red blood cell transfusion with MBD is a novel finding that may be related to iron overload and that merits further study.

Hypophosphatemia as an Early Metabolic Bone Disease Marker in Extremely Low-Birth-Weight Infants After Prolonged Parenteral Nutrition Exposure

BACKGROUND

Early metabolic bone disease (MBD) detection is important in preterm infants to decrease long-term consequence. We aim to explore the early MBD biochemical marker in extremely low-birth-weight (ELBW) infants.

METHODS

Retrospective cohort study of 95 preterm infants born in a tertiary care-level neonatal intensive care unit between January 2015 and June 2018, with birth weight <1000 g. Thirty-five infants were "nothing by mouth" for >14 days and categorized as the high-risk group; the remaining 60 were categorized as the control group. Mineral intake in the first 14 days and the trend of serum calcium (Ca), phosphorus (P), and alkaline phosphatase (ALP) levels were compared in both groups.

RESULTS

The Ca and P supplementation in the first 2 weeks of life were inadequate in both groups. Compared with the control group, significantly lower serum P (mg/dL) levels were noted in the high-risk group on weeks 2 (3.65 ± 1.2 vs 4.67 ± 1.45; P < .001), 4 (3.21 ± 0.95 vs 5.83 ± 1.18; P < .0001), and 6 (3.94 ± 1.1 vs 6.22 ± 0.78; P <.0001). There was no significant difference in the serum Ca level, and significantly higher ALP (U/L) levels were found up until 2 months of life in the high-risk group (458.36 ± 189.02 vs 335.7 ± 111.51; P < .014).

CONCLUSION

Hypophosphatemia developed as early as 2 weeks old in high-risk preterm infants because of inadequate supplementation. Neither the serum Ca or ALP levels were affected. Thus, the routine monitoring of serum P level should be started 2 weeks after birth for early MBD detection in extremely ELBW infants.

Electrochemical Detection and Capillary Electrophoresis: Comparative Studies for Alkaline Phosphatase (ALP) Release from Living Cells

Alkaline phosphatase (ALP) is one of the main biomarkers that is clinically detected in bone and liver disorders using optical assays. The electrochemical principle is important because point-of-care testing is increasing dramatically and absorbance techniques hardly compete with the medical revolution that is occurring. The detection of ALP using electrochemical detection is contributing to the integration systems field, and hence enhancing the detection of biological targets for pharmaceutical research and design systems. Moreover, in vitro electrochemical measurements use cost effective materials and simple techniques. Graphite screen-printed electrodes and linear sweep voltammetry were used to optimize the electrochemistry of the enzymatic product p-aminophenol using the enzyme kinetic assay. ALP release from embryonic and cancer cells was determined from adhesion cell culture. Additionally, capillary electrophoresis and colorimetric methods were applied for comparison assays. The resulting assays showed a dynamic range of ALP ranging from 1.5 to 1500 U/L, and limit of detection of 0.043 U/L. This was achieved by using 70 μL of the sample and an incubation time of 10 min at an optimal substrate concentration of 9.6 mM of p-aminophenol phosphate. A significant difference (p < 0.05) was measured between the absorbance assays. This paper demonstrates the advantages of the electrochemical assay for ALP release from cells, which is in line with recent trends in gene expression systems using microelectrode array technologies and devices for monitoring electrophysiological activity.

Effect on metabolic bone disease markers in the neonatal intensive care unit with implementation of a practice guideline

OBJECTIVES

To determine the effect of implementing a 2015 policy for the screening, prevention, and management of metabolic bone disease for very low birth weight (VLBW) infants in two Level IV NICUs.

STUDY DESIGN

Retrospective cohort study of VLBW infants in the 2 years prior to (2013-2014) and after (2016-2017) policy implementation.

RESULTS

We identified 316 VLBW infants in 2013-2014 and 292 in 2016-2017 who met study criteria. After policy implementation, vitamin D supplementation began earlier (20.1 ± 15.5 days vs 30.2 ± 20.1 days, p < 0.0005), the percentage of infants with alkaline phosphatase obtained increased (89.7% vs 76.3%, p < 0.0005), while the percentage of infants with alkaline phosphatase >800 IU/L (11.7 vs 4.5%, p = 0.0001) and phosphorous <4 mg/dL (14.2% vs 7.9%, p = 0.014) fell significantly.

CONCLUSIONS

After policy implementation, vitamin D supplementation began significantly earlier and the rate of detecting abnormal biochemical markers of metabolic bone disease decreased significantly.

The Effect of Daily Exercise Program on Bone Mineral Density and Cortisol Level in Preterm Infants with Very Low Birth Weight: A Randomized Controlled Trial

PURPOSE

This randomized controlled double-blinded experimental study was carried out to determine the effects of the daily exercise program on bone mineral density and cortisol level in preterm infants with VLBW matched for birth weight, gestation week, and gender.

DESIGN AND METHODS

The study was carried out with preterm infants (n = 24) hospitalized in the NICU of a tertiary hospital. Ethical committee approval, institutional permission, parental written consent were obtained. A daily exercise program was implemented in preterm infants in the exercise group for 30 days, once a day, and continuing for 7-10 min. Before and after the study the following were evaluated in preterm infants in the exercise and control group: anthropometric measurements, tibia speed of sound (SOS) for bone mineral density, serum cortisol levels.

RESULTS

Serum cortisol levels (p = 0.05) were decreased, bone SOS values in the exercise group were increased (p = 0.009), after the study. The difference between pre-, post-study bone SOS and serum cortisol values of infants in the exercise group were high (p > 0.05). Percentage increases in anthropometric values in the exercise group were higher than the control group after the study (for all; p > 0.05).

CONCLUSIONS

The daily exercise program has positive effect on bone SOS and serum cortisol values in preterm infants. Neonatal nurses can implement the daily exercise program in clinical practice. Trial registration numberClinicaltrials.govNCT03773679.

Screening for Metabolic Bone Disease of prematurity

Metabolic bone disease (MBD) of prematurity remains a significant comorbid condition in preterm, low birth weight infants. As the majority of in utero calcium (Ca) and phosphorus (Phos) accretion occurs during the third trimester, many of these children have inadequate mineral stores and are at risk for deficiencies of Ca and Phos. While fortification of formula has allowed for increased mineral delivery to premature infants, intestinal immaturity prevents optimal absorption. This is compounded by immobilization, delayed establishment of enteral feeds, long term parenteral nutrition and medications that may alter mineral levels. Over time, biochemical changes occur and accompany MBD, with poor bone mineralization during this period increasing the risk for complications such as osteopenia, rickets and fractures. Screening is largely based on risk factors, but despite the 2013 AAP Consensus Statement, there remains significant variation in screening practices across institutions. A combination of laboratory and radiologic testing is often used to diagnose and manage MBD of prematurity, but there exists a lack of consensus on which screening tests and thresholds to use. This is in part related to a lack of normative data and clinical trials for preterm infants, and a result, a lack of evidence-based guidelines on the diagnosis and timing of potential treatment. Biochemical markers, such as serum Phos, alkaline phosphatase (ALP) and parathyroid hormone (PTH), have shown some benefit in the diagnosis of MBD in some studies, but have not always been reproducible. Radiographs may identify different degrees of skeletal changes, but these changes may not be detected until later in MBD development. Other modalities, such as DXA and ultrasound, have also been used, but these may be limited by lack of standards in preterm infants or lack of availability in some centers. Further research, more specifically clinical trials, are needed to determine which combination of tests can detect MBD at its earliest, in order to promote early treatment and prevent short- and long-term complications of MBD.

Association of Protein and Vitamin D Intake With Biochemical Markers in Premature Osteopenic Infants: A Case-Control Study

Osteopenia in preterm infants (OP) remains an important challenge and is largely dependent on nutritional post-natal intake of factors influencing bone mineralization. We conducted a prospective case-control study to evaluate the importance of protein and vitamin D intake in OP among neonates with birth weight <1,250 g. Simultaneous serum parathyroid hormone (PTH), alkaline phosphatase (ALP), calcium (Ca), phosphorus (P), vitamin D and protein levels were measured during the first six post-natal weeks. At 6 weeks of age, OP was evaluated using wrist radiographs. Comparisons were analyzed using multivariate linear regression, receiver operating characteristic curves, χ2 and Wilcoxon Rank Sum. Of the 26 premature infants enrolled, 13 developed radiographic OP. Daily protein intake (coef = -0.40, p = 0.001) and vitamin D concentrations (21 ± 5.7 ng/ml) were significantly lower in the OP group compared to non-OP subjects. ALP concentration exceeding 619 IU/L, sensitivity of 76.9% and specificity of 75%, was predictive of OP at 6 weeks post-natally. PTH levels were higher at 6 weeks in OP subjects (193 ± 102.5 pg/ml, p < 0.001) compared to non-OP subjects. The findings in this study support the role of vitamin D and protein intake in the development of OP in VLBW infants and inform future practice and research on best practices for OP management.

Overview of Optical and Electrochemical Alkaline Phosphatase (ALP) Biosensors: Recent Approaches in Cells Culture Techniques

Alkaline phosphatase (ALP), which catalyzes the dephosphorylation process of proteins, nucleic acids, and small molecules, can be found in a variety of tissues (intestine, liver, bone, kidney, and placenta) of almost all living organisms. This enzyme has been extensively used as a biomarker in enzyme immunoassays and molecular biology. ALP is also one of the most commonly assayed enzymes in routine clinical practice. Due to its close relation to a variety of pathological processes, ALP's abnormal level is an important diagnostic biomarker of many human diseases, such as liver dysfunction, bone diseases, kidney acute injury, and cancer. Therefore, the development of convenient and reliable assay methods for monitoring ALP activity/level is extremely important and valuable, not only for clinical diagnoses but also in the area of biomedical research. This paper comprehensively reviews the strategies of optical and electrochemical detection of ALP and discusses the electrochemical techniques that have been addressed to make them suitable for ALP analysis in cell culture.

Nutritional Support of Very Low Birth Weight Infants in a Tertiary Center in a Developing Country

BACKGROUND

Very low birth weight infants (VLBWIs) are at high risk for nutritional deficiency. Enteral feeding is usually challenged by increased risk of necrotizing enterocolitis (NEC). The nutritional needs of VLBWIs are usually dependent on parenteral nutrition during early postnatal life. This study aimed to evaluate the nutritional service of VLBWIs at Jordan University Hospital.

METHODS

This was a prospective follow-up study of VLBWIs with birth weight ≤ 1,500 g. Data were extracted from medical charts and laboratory database.

RESULTS

In total, 43 VLBWIs met our inclusion criteria; of them, 21% were extremely low birth weight infants (ELBWIs). The mean gestational age was 29 weeks, and the mean birth weight was 1,218 g. The mean age of starting feeds was 3 days. Mean full feed age is 2 weeks. The most common side effect of total parenteral nutrition (TPN) was hypertriglyceridemia (35%).

CONCLUSIONS

Nutritional care of VLBWIs is well established in our center. Initiating fortification earlier and working to increase mother's own breast milk supply is vital to improve growth in low resource setting.

The effect of thyroid functions on osteopenia of prematurity in preterm infants

Background It is known that thyroid hormones have effects on bone development. In particular, the effect of thyroid hormones on osteopenia of prematurity (OOP) has not been examined in preterm infants. Our study aimed to examine the relationship between OOP and congenital hypothyroidism (CH) in preterm infants. Methods Very low birth weight infants (VLBW, <1500 g) were included in the study. Thyroid-stimulating hormone (TSH) and free thyroxine (fT4) levels were measured on postnatal day 5. Serum calcium, phosphorus and alkaline phosphatase (ALP) levels were studied as standard screening parameters for OOP at postnatal week 4. Patients with serum ALP level >700 IU/L were included in the OOP group. We intended to figure out the relationship between OOP and CH in infants. Results In our study, OOP frequency was 14.9% among 543 VLBW infants. There was no statistically significant difference between groups with and without CH (21.7% and 14.8%, respectively) in terms of OOP (p=0.632). Gestational age (GA) was significantly lower in infants with diagnosed OOP (p<0.001, p<0.001, respectively). In addition, the prevalence rates of mothers with preeclampsia, small for gestational age (SGA), respiratory support requirement, late-onset neonatal sepsis (LOS), bronchopulmonary dysplasia (BPD) and full enteral feeding time were found to be higher in the OOP group (p<0.05). Conclusions We found that thyroid hormones had no effect on OOP in preterm infants. Therefore, future randomized controlled studies as well as long-term outcome studies are warranted on this topic.

Evaluation of A Concentrated Preterm Formula as a Liquid Human Milk Fortifier in Preterm Babies at Increased Risk of Feed Intolerance

There are concerns around safety and tolerance of powder human milk fortifiers to optimize nutrition in preterm infants. The purpose of this study was to evaluate the tolerance and safety of a concentrated preterm formula (CPF) as a liquid human milk fortifier (HMF) for premature infants at increased risk of feeding intolerance. We prospectively enrolled preterm infants over an 18-month period, for whom a clinical decision had been made to add CPF to human milk due to concerns regarding tolerance of powder HMF. Data on feed tolerance, anthropometry, and serum biochemistry values were recorded. Serious adverse events, such as mortality, necrotizing enterocolitis (NEC), and sepsis, were monitored. A total of 29 babies received CPF fortified milk during the study period. The most common indication for starting CPF was previous intolerance to powder HMF. Feeding intolerance was noted in 4 infants on CPF. The growth velocity of infants was satisfactory (15.9 g/kg/day) after addition of CPF to feeds. The use of CPF as a fortifier in preterm babies considered at increased risk for feed intolerance seems well tolerated and facilitates adequate growth. Under close nutrition monitoring, this provides an additional option for human milk fortification in this challenging subgroup of preterm babies, especially in settings with limited human milk fortifier options.

Mineral Homeostasis and Effects on Bone Mineralization in the Preterm Neonate

Most bone formation and mineralization occurs late in gestation. Accretion of adequate minerals is a key element of this process and is often interrupted through preterm birth. In utero, mineral transport is accomplished via active transport across the placenta and does not require fetal hormone input. Postnatal mineral homeostasis requires a balance of actions of parathyroid hormone, calcitonin, and vitamin D on target organs. Preterm birth, asphyxia, acidosis, and prolonged parenteral nutrition increase the risk of mineral imbalance and metabolic bone disease (MBD). Aggressive postnatal nutrition is key to preventing and treating MBD in preterm infants.