Calcium and phosphorus requirements of low birth weight infants: a nutritional and endocrinological perspective

A portable system for measuring bone mineral density in the pre-term neonatal forearm

Current systems used to measure bone mineral content (BMC) in the neonate have the major drawback that the child must be well enough to be moved to the scanner. Consequently, low birth weight pre-term neonates, a group at particular risk of mineral compromise, cannot be measured. This paper describes a portable neonatal bone mineral device capable of measuring bone mineral in the incubator. It uses a radiation sensitive, charge coupled device (CCD) to acquire a bone mineral image enabling bone mineral to be measured at various sites. It measures bone mineral density (BMD) with a precision of 5.5 mg cm-2 in vivo, reduced to 7.5 mg cm-2 when repositioning between scans is taken into account. The procedure takes under 5 min with an image acquisition time of 30 s and an absorbed radiation dose to skin of 6 microSv. Calibration has been undertaken with aluminium foils of differing thickness to confirm the linearity of the system throughout the intended measurement range. A regression line fitted to the data demonstrated linearity and correlation between BMD and aluminium thickness with r = 0.99 (p < 0.0001). Preliminary measurements on pre-term neonates show values of BMD ranging from 43 to 115 mg cm-2 in babies aged 23-41 weeks post-conception. These figures are within the linear range of the system.

Sudden infant death syndrome (SIDS): immunoglobulins and hypoxia

A body of opinion suggests that immunological overstimulation of the gastrointestinal and respiratory mucosa is involved in SIDS. The local stimulation of immunoglobulin concentration in the respiratory mucosa is said to be the consequence of an accentuated reaction to a trivial infection (1-4). One hypothesis is that an accentuated airways reactivity plays a key role in the events leading to SIDS and cites the final insult as oxygen lack, low oxygen stores, high oxygen usage and cardiorespiratory failure (5). We hypothesize that hypoxia and antioxidants exacerbate disorders of the paracrine interaction in the airways mucosa leading to overproduction of immunoglobulins. Administration of vitamin E above dietary needs to hypoxic chicks increased the immune response. The effects were considered synergistic in elevated production of immunoglobulins, and in their function as antioxidants (6). The oxygen lack, low oxygen stores, high oxygen usage and cardiorespiratory failure (5) are factors capable of provoking an overstimulated immune response in the respiratory mucosa. When levels of T-helper/inducer cells are maintained in AIDS patients' blood plasma, survival time is extended (7). This paper investigates the role of 1,25 (OH) 2D3 in suppression of T-helper/inducer lymphocyte activity in vitro (8,9,34,36), and the failure of activated pulmonary alveolar macrophages (PAM) to produce sufficient 1,25(OH)2D3 to inhibit beta-cell proliferation before differentiation to immunoglobulin secreting cells (4,36).

High turnover osteopenia in preterm babies

Osteopenia is common in preterm babies, but its pathogenesis is uncertain. In this study bone density in babies was quantitated, postnatal bone mineralization compared to expected intrauterine bone mineralization and the pathogenesis of osteopenia investigated. Healthy babies (103 term, 76 preterm) were examined clinically, biochemically and radiologically the day after birth and at a time corresponding to expected full term gestation. Appendicular bone density was quantitated by magnification radiogrammetry, using the humeral cortical index (CI). The CI of preterm and term babies was similar the day after birth. In preterm babies elevated serum alkaline phosphatase and high urinary hydroxyproline indicated increased bone turnover. The CI of preterm babies at expected full term gestation was lower (p = 0.0001) than that of term babies at birth, implying that postnatal bone mineralization lagged behind expected intrauterine bone mineralization. Radiologic data suggested increased endosteal resorption rather than decreased bone formation. At expected full term gestation the preterm babies had higher serum alkaline phosphatase and urinary calcium, phosphate, c-AMP and hydroxyproline (p = 0.0001) than term babies at birth, and 15% had periosteal reactions. The biochemical as well as the radiologic data therefore indicated high turnover osteopenia in preterm babies. We conclude that postnatal bone mineralization in preterm babies lagged significantly behind expected intrauterine bone mineralization and that the osteopenia observed in preterm babies is caused by increased bone resorption and not by decreased bone formation. The cause(s) of this high turnover osteopenia, however, remains to be ascertained.

Calcium and phosphorus metabolism in the premature infant

During the last trimester of pregnancy, there is a sixfold increase in fetal calcium and phosphorus accumulation. Unsupplemented human breast milk may not provide sufficient calcium and phosphorus for the rapidly growing preterm infant to match the accumulation that should have taken place in utero and to permit normal bone mineralization. Rickets of prematurity may present clinically between the 6th and 12th postnatal week. The clinical diagnosis may be confirmed using simple biochemical tests. Inadequate mineral substrate intake, particularly of phosphorus, is the most common cause, although a delay in the maturation of the renal enzyme, 1-alpha hydroxylase, with low plasma concentrations of 1,25-dihydroxyvitamin D, may also occur. The biochemical response to treatment can be determined by documenting a fall in plasma alkaline phosphatase activity and a rise in plasma phosphate concentration and urinary phosphate excretion.

Role of the source of phosphate salt in improving the mineral balance of parenterally fed low birth weight infants

Because the monobasic potassium phosphate salt (monobasic) improves the solubility of calcium and phosphorus in amino acid plus dextrose solutions, compared with the current mixtures of monobasic plus dibasic salts (dibasic), we tested the bioavailability and clinical effects of monobasic in 16 parenterally fed low birth weight infants at standard (n = 8) and high levels (n = 8) of mineral intakes. A constant infusion of macronutrients and vitamin D was provided in a crossover design of two four-day periods. With standard intakes of calcium (35 mg/kg/day, 0.9 mmol/kg/day) and phosphorus (30 mg/kg/day, 1 mmol/kg/day), there was no difference between monobasic and dibasic regimens on balance data or plasma biochemical monitoring (calcium, phosphorus, pH, carbon dioxide pressure, base excess, 1,25-dihydroxyvitamin D, 25-hydroxyvitamin D). With the use of the monobasic regimen, the mineral intakes were doubled without precipitation in the infusate: calcium, 70 mg/kg/day (1.8 mmol/kg/day), and phosphorus, 55 mg/kg/day (1.7 mmol/kg/day). This led to increased apparent retention of both calcium (63 +/- 5 mg/kg/day, 1.58 +/- 0.12 mmol/kg/day) and phosphorus (52 +/- 4 mg/kg/day, 1.67 +/- 0.14 mmol/kg/day) compared with that for standard levels of mineral intake. The improvement of calcium-phosphorus balance was accompanied by more severe calciuria (9 +/- 2 mg/kg/day, 0.2 +/- 0.05 mmol/kg/day) and by metabolic compensation for an increased acid load. In addition to the possibility of exceeding the buffering capacity of the infant, this relative acidosis could also be evidence of improved bone mineralization.

Vitamin D and mineral metabolism in the very low birth weight infant receiving 400 IU of vitamin D

STUDY OBJECTIVE

To examine (1) the effect of vitamin D intake (380 to 480 IU daily) on plasma 25-hydroxyvitamin D (25-OHD) and 1,25-dihydroxyvitamin D (1,25-(OH)2D) concentrations and (2) the relationship of 1,25-(OH)2D to calcium and phosphorus absorption and retention in the very low birth weight infant receiving a preterm infant formula.

SUBJECTS

Eleven "well" infants with a birth weight and gestational age (mean +/- SD) of 1078 +/- 128 gm and 29 +/- 1.9 weeks, respectively, were studied for a 3-week period. Weight and postnatal age (mean +/- SD) at the beginning of the study were 1132 +/- 56 gm and 16 +/- 6 days, respectively. All infants were fed a preterm infant formula and tolerated a full enteral intake (120 kcal/kg/day) for the duration of the study.

INTERVENTIONS

Plasma 25-OHD and 1,25-(OH)2D concentrations were measured at the beginning of the study and at the beginning of each 48-hour balance period. Calcium and phosphorus balance studies (n = 33) were performed weekly.

MAIN RESULTS

Plasma 25-OHD (30 +/- 10 ng/ml) and 1,25-(OH)2D (54 +/- 14 pg/ml) concentrations were normal at the beginning of the study. Plasma 25-OHD values did not change, but 1,25-(OH)2D values increased (p less than 0.001) throughout the study. Plasma 1,25-(OH)2D concentrations were not related to calcium or phosphorus absorption and retention, but were a linear function of postconceptional age.

CONCLUSIONS

Normal vitamin D status and activity are maintained in the very low birth weight infant fed a high calcium formula (380 to 480 IU of vitamin D daily). Plasma 1,25-(OH)2D concentrations are not related to calcium absorption but are linearly related to maturity.

Social and biological correlates of localized enamel hypoplasia of the human deciduous canine tooth

Recent studies of teeth from prehistoric children have reported a localized, roughly circular patch of deficient enamel on the labial aspect of the primary canine, which reaches its highest prevalence in the Upper Paleolithic of Europe. This study reports social and biological correlates of 33 affected kindergarten-aged children from Vancouver, Canada (2.4% of 1,350 examined). Affected children can be characterized as coming from low-income families often of East Asian or Chinese origin in which there is a degree of milk avoidance and reduced breastfeeding. The defect appears to be due to minor physical trauma to the face approximately 6 months after birth occasioned by normal motor development, involving handling and mouthing objects, which damages the developing tooth crown through deficient cortical bone over the canine crypt. Reduced cortical bone in the face of the infant is attributed to nutritional factors, involving calcium deficiency, of the mother and/or developing infant.

Sudden infant death syndrome: congenital copper deficiency

A previous paper describes specific respiratory toxins likely to be associated with Sudden Infant Death Syndrome (SIDS). This paper describes ultrastructural abnormalities in the lung and other tissues in congenital copper deficiency. Congenital copper deficiency is associated with tissue anoxia defects in the development of myelin through a failure of phospholipid synthesis. Phospholipid is part of the membrane structure of cells. The paucity of elastin is attributed to a loss of lysyl oxidase activity. Hypoventilation is considered a feature of SIDS.

Phosphorus deficiency syndrome in very low birth weight infants

Inadequate dietary phosphorus intake is a contributing factor to the occurrence of metabolic bone disease in very low birth weight infants. This article reviews the clinical presentation and the pathophysiology of the phosphorus deficiency syndrome in premature infants. Recommendations for therapy and prevention of phosphorus deficiency are presented.

Measurement of bone mineral content in the human fetus by photon absorptiometry

A photon absorptiometer designed to measure the bone mineral content (BMC) of the radius and ulna in premature or term babies was used to examine 34 forearm specimens obtained from 25 male and 9 female babies dying before or up to 13 weeks after birth. Gestational age, foot and crown-heel lengths and birth weight were recorded. Radiographic measurements showed that the midshaft of the radius can be located with a positioning error of +/- 1.28 mm (+/- 2 S.E.E.) from the distance between the distal ulnar styloid process and proximal tip of the olecranon, both of which can be palpated in vivo. Scanning at 5 sites showed that effects of positioning errors on BMC measurements are least at the midshaft site. Subsequent measurements of the ash weight of sections of the radius and ulna, centred on the midshaft of the radius, showed that ash weight/unit length can be estimated with a standard error 2.99 mg/cm from scan data.

Theory about interrelationships between macromineral nutrients and growth rate during recovery from undernutrition

Previous papers of our group have reported that, in the first stages of nutritional recovery, the needs of undernourished infants, in terms of Protein Calories percentage (P%) were higher than normal, and similar to those of other mammals which double their birth weight faster than man. During this period, a high dietary P% produces an accelerated catch-up growth. Therefore, Calcium and Phosphorus balances increase proportionally to weight gain rate (WGR), and Calcium retention per gram of new tissue is dependent on dietary Calcium/Protein ratio. On the other hand, Bernhart demonstrated that there was a direct correlation between the growth rate of the sucklings of several species, including humans, and the percentage of protein and ash in the fluid milk. As a consequence of these facts, we assume that during catch-up growth, in order to attain a normal body composition, dietary level of essential minerals must be related to factors affecting weight gain. These relationships suggest the hypothesis that, during the recovery from undernutrition, in order to meet the needs of the catch-up growth allowed by the Protein/Calories ratio, Calcium and Phosphorus milk concentrations would be in relation to the Protein/Calorie concentration. In this way, Calcium and Phosphorus concentrations might be the limiting factors for attaining a normal body composition. This hypothesis might also be generalized to other minerals in order to prevent them from becoming the limiting factors for attaining a normal body composition.

Plasma 1.25-dihydroxyvitamin D concentrations in preterm infants

1.25-Dihydroxyvitamin D concentrations were measured in 10 preterm infants (mean gestational age 29 weeks, range 26-32; mean birthweight 1226 g, range 980-1700). Total parenteral nutrition was begun after birth and partial enteral feeding was started at 1 week of age. Total enteral feeding was achieved at a mean age of 26 days (range 16-47). The daily vitamin D3 intake was about 400 I. U. No clinical, chemical or radiological signs of rickets were observed. The mean 1.25-dihydroxyvitamin D concentration +/- SEM was 103.2 +/- 24.0 pmol/l at 1 week (range 9.6-252.0), 141.6 +/- 26.4 at 3 weeks (range 31.2-324.0), 153.6 +/- 21.6 at 6 weeks (range 67.2- 256.8), 165.6 +/- 24.0 at 9 weeks (range 74.4-307.2) and 153.6 +/- 21.6 at 12 weeks (range 76.8-268.8) postnatal age. The mean values at 6, 9 and 12 weeks were significantly higher (p resp. less than 0.01, less than 0.002 and less than 0.005) than in adults (88.8 +/- 7.2; n = 27). 1.25-Dihydroxyvitamin D concentrations were highly variable and did not correlate with 25-hydroxyvitamin D concentrations, plasma calcium and phosphorus concentrations and plasma alkaline phosphatase levels, nor with illness nor postnatal age. The data demonstrate that preterm infants are capable of producing high plasma levels of 1.25-dihydroxyvitamin D.