Metabolic Bone Disease of Prematurity: Diagnosis and Management

Pulsed Vibro-Acoustic Analysis Technique for Monitoring Bone Health in Preterm Infants: A Pilot Study

Despite advances in neonatal care, metabolic bone disease of prematurity (MBDP) remains a common problem in preterm infants. The development of non-invasive and affordable diagnostic approaches can be highly beneficial in the diagnosis and management of preterm infants at risk of MBDP. In this study, we present an ultrasound method called pulsed vibro-acoustic analysis to investigate the progression of bone mineralization in infants over time versus weight and postmenstrual age. The proposed pulsed vibro-acoustic analysis method is used to evaluate the vibrational characteristics of the bone. This method uses the acoustic radiation force of ultrasound to vibrate the bone. The generated acoustic waves are detected using a hydrophone placed on the skin over the tibia. The frequency of vibration and the speeds of received acoustic waves have information regarding the material property of the bone. We examined the feasibility of this method through an in vivo study consisting of 25 preterm and 10 full term infants. The pulsed vibro-acoustic data were acquired longitudinally in preterm infants with multiple visits and at a single visit in full term infants. Speed of sound and mean peak frequency of slow and fast sound waves recorded by hydrophone were used to analyze bone mineralization progress. Linear mixed model was used for statistical analysis in characterizing the mineralization progress in preterm infants compared to data from full term subjects. Significance changes in wave parameters (speed of sound and mean peak frequency) with respect to the postmenstrual age and weight in preterm infants were observed with p-values less than 0.05. Statistical significances in speed of sound measurement for both fast and slow waves were observed between preterm and full term infants, with p-values of <0.01 and 0.02, respectively. The results of this pilot study indicate the potential use of vibro-acoustic analysis for monitoring the progression of bone mineralization in preterm infants.

European survey showed wide variations in diagnostic procedures and management strategies for metabolic bone disease of prematurity in 22 countries

AIM

The aim of this study was to evaluate the clinical relevance, diagnostic procedures and treatment strategies for metabolic bone disease in preterm infants across Europe.

METHODS

An e-survey was distributed by email to 545 neonatal units in 38 European countries between July and October 2021. The protocol was based on the Checklist for Reporting Results of Internet E-Surveys.

RESULTS

In total, 76 neonatal units (14%) from 22 European countries (58%) completed the e-survey. In the 12 months prior to the survey, 29% of 76 units reported at least one symptomatic case of fracture associated with metabolic bone disease of prematurity, and 18% of 76 units reported at least one case of craniofacial deformity. Most centres followed local guidelines for diagnosis (77% of 73 units) and treatment (63% of 72 units). Alkaline phosphatase was the blood marker most used for treatment indication (81% of 72 units), and phosphate supplementation was the treatment most used (82% of 71 units).

CONCLUSION

Metabolic bone disease of prematurity remains clinically relevant. Wide variations in diagnostic procedures and management strategies were observed in European neonatal units. Evidence-based consensus guidelines appear urgently needed to reduce the number of symptomatic cases.

Skeletal consequences of preterm birth in pigs as a model for preterm infants

Preterm birth affects about 10% of all live births with many resultant health challenges, including metabolic bone disease of prematurity (MBDP), which is characterized by elevated alkaline phosphatase, suppressed phosphate, and deficient skeletal development. Because of the lack of an animal model, very little is known about bone structure, strength, and quality after preterm birth. This study investigated the utility of a pig model to replicate clinical features of preterm birth, including MBDP, and sought to determine if early postnatal administration of IGF-1 was an effective treatment. Preterm pigs, born by caesarean section at 90% gestation, were reared in intensive care facilities (respiratory, thermoregulatory, and nutritional support) and compared with sow-reared term pigs born vaginally. Preterm pigs were systemically treated with vehicle or IGF-1 (recombinant human IGF-1/BP-3, 2.25 mg/kg/d). Tissues were collected at postnatal days 1, 5, and 19 (the normal weaning period in pigs). Most bone-related outcomes were affected by preterm birth throughout the study period, whereas IGF-1 supplementation had almost no effect. By day 19, alkaline phosphatase was elevated, phosphate and calcium were reduced, and the bone resorption marker C-terminal crosslinks of type I collagen was elevated in preterm pigs compared to term pigs. Preterm pigs also had decrements in femoral cortical cross-sectional properties, consistent with reduced whole-bone strength. Thus, the preterm pig model replicates many features of preterm bone development in infants, including features of MBDP, and allows for direct interrogation of skeletal tissues, enhancing the field's ability to examine underlying mechanisms.

A Quality Improvement Project to Decrease Fractures Secondary to Metabolic Bone Disease of Prematurity

Introduction

Osteopenia of prematurity is common in the neonatal intensive care unit, with an incidence of up to 54% in extremely low birthweight infants. The baseline fracture rate in our level IV midwestern neonatal intensive care unit was 13%, with poor compliance with recommended intakes of calcium, calcium:phosphorus ratio, and Vitamin D.

Methods

A multidisciplinary team implemented a screening guideline through four Plan-Do-Study-Act cycles, which addressed staff education, vitamin D screening, and incorporation of calcitriol. In total, 150 patients born between October 1, 2019 and April 30, 2023 were screened for mineral intakes, laboratory abnormalities, and the development of fractures or osteopenia.

Results

The incidence of fractures decreased from 13% to 5.3%. Compliance with mineral intakes improved for calcium, calcium: phosphorus ratio, and Vitamin D. Infants born after the guideline were 4.8 times less likely to develop fractures.

Conclusion

Quality improvement methodology successfully decreased the rate of fractures due to osteopenia of prematurity and increased compliance with recommended mineral intakes.

Role of fibroblast growth factor-23 as an early marker of metabolic bone disease of prematurity

PURPOSE

Metabolic bone disease of prematurity (MBDP) remains a significant cause of morbidity in extremely premature newborns. In high-risk patients, suspected diagnosis and subsequent treatment modifications, with limitations in terms of sensitivity and specificity, rely on low phosphorus levels and/or high levels of alkaline phosphatase (ALP). We investigated the potential of fibroblast growth factor-23 (FGF23) as an early marker for MBDP when measured at 3-4 weeks of life in at-risk patients.

METHODS

A single-center prospective observational non-interventional study including preterm newborns of both sexes, with a gestational age of less than 32 weeks and/or a birth weight of less than 1500 g. In the standard biochemical screening for MBDP performed between 3 and 4 weeks of life within a nutritional profile, the determination of FGF23 was included along with other clinical and metabolic studies. The study was conducted at Marqués de Valdecilla University Hospital in Santander, Spain, from April 2020 to March 2021. Participants provided informed consent. Biochemical analyses were conducted using various platforms, and follow-up evaluations were performed at the discretion of neonatologists. Patients at high risk for MBDP received modifications in treatment accordingly. The sample was descriptively analyzed, presenting measures of central tendency and dispersion for continuous variables, and absolute numbers/percentages for categorical ones. Tests used included t-tests, Mann‒Whitney U tests, chi-square tests, logistic regressions, Pearson correlation, and ROC curve analysis (IBM SPSS Statistics version 19). Significance level: P < 0.05.

RESULTS

In the study involving 25 at-risk premature newborns, it was found that 20% (n = 5) were diagnosed with MBDP. Three of these patients (60%) were identified as high-risk based on standard biochemical evaluation at 3-4 weeks of age, while the other two patients (40%) were diagnosed in subsequent weeks. However, in all 5 patients, measurement of FGF23 levels would allow for early identification and optimization of treatment before other markers become altered. Low levels of FGF23 at 3-4 weeks, even with normal phosphorus and ALP levels, indicate the need for modifications in nutritional supplementation.

CONCLUSIONS

MBDP remains a significant concern in extremely premature newborns. Current diagnostic methods rely on limited biochemical markers. Early detection of low FGF23 levels enables timely interventions, potentially averting demineralization.

Diagnostics of Metabolic Bone Disease in Extremely Preterm Infants-Clinical Applicability of Bone Turnover Biochemical Markers and Quantitative Ultrasound

BACKGROUND

Significant improvement in neonatal care has enabled increasing survival of preterm infants. Metabolic bone disease of prematurity is often overlooked due to other comorbidities of preterm birth. The best approach is screening and prevention of the disease in high-risk infants such as preterm infants.

AIM

We followed up the clinical, radiological, and serum biochemical markers of metabolic bone disease in extremely preterm infants (<28 weeks of gestation). The clinical applicability and validation of C-terminal telopeptide of type I collagen (CTX-I) as a novel bone turnover marker were assessed. Standard and novel biochemical bone turnover markers and quantitative ultrasound were compared.

METHOD

Patients' data were collected from medical records. Assessments of calcium, phosphate, alkaline phosphatase, bone-alkaline phosphatase, CTX-I, and quantitative ultrasound were prospectively performed twice in 42 extremely preterm infants at postmenstrual ages of 30-32 weeks and 36-40 weeks. Bone mineral density was measured by quantitative ultrasound.

CONCLUSION

Phosphate, alkaline phosphatase, bone alkaline phosphatase, calcium, or ionized calcium are not related to gestational age, but bone mineral density, measured by quantitative ultrasound, is related. There is no correlation between standard and novel biochemical markers and quantitative ultrasound for the identification of metabolic bone disease.

Biomarkers and Biochemical Indicators to Evaluate Bone Metabolism in Preterm Neonates

The purpose of the present study was to evaluate the concentrations of some bone turnover markers in preterm neonates with uncomplicated clinical course in the first month of life. Samples from 13 preterm neonates were collected at three different times: at birth (T0) from umbilical cord blood (UCB); and at 15 (T1) and 30 (T2) days of life from peripheral blood (PB). The concentrations of calcium (Ca), phosphate (P), total alkaline phosphatase (ALP), Collagen Type 1 Amino-terminal Propeptide (PINP), osteocalcin (OC), Collagen Type 1 Carboxyl-Terminal Telopeptide (CTX) and Leptin were assessed. A statistically significant difference for ALP concentration at birth versus T1 and T2 was found. An evident increase in the median concentrations of CTX, OC and PINP from T0 to T2 were observed. A significant difference was also found for Leptin concentration at T0 compared to T1. In preterm infants, in the absence of acute or chronic medical conditions and without risk factors for metabolic bone disease (MBD) of prematurity, there is a significant increase in bone turnover markers during the first month of life. The knowledge of the variations in these markers in the first weeks of life, integrated by the variations in the biochemical indicators of bone metabolism, could help in recognizing any conditions at risk of developing bone diseases.

Potential Micronutrient Deficiencies in the First 1000 Days of Life: The Pediatrician on the Side of the Weakest

PURPOSE OF REVIEW

This study is to examine potential micronutrient deficiencies and any need for supplementation in children following specific diet plans in the first 1000 days of life.

RECENT FINDINGS

Optimal nutrition in the first 1000 days of life has a lifelong positive impact on child development. Specific intrauterine and perinatal factors, pathological conditions, and dietary restrictions can represent potential risk factors for micronutrient deficiencies in the first 1000 days of life, which can have negative systemic consequences. Preterm and low-birth-weight infants are intrinsically at risk because of immature body systems. Children affected by cystic fibrosis are prone to malnutrition because of intestinal malabsorption. The risk of micronutrient deficiency can increase in various situations, including but not limited to children following selective dietary regimens (vegetarian and vegan diets and children affected by specific neuropsychiatric conditions) or specific dietary therapies (children affected by food allergies or specific metabolic disorders and children following restricted diet as a part of therapeutic approach, i.e., ketogenic diet for epilepsy). In light of this situation, the micronutrient status in these categories of children should be investigated in order to tailor strategies specific to the individual's metabolic needs, with a particular focus on deficiencies which can impair or delay the physical and cognitive development of children, namely, vitamin B12, vitamin D and folic acid, as well as oligo-elements such as iron, zinc, calcium, sodium, magnesium, and phosphorus, and essential fatty acids such as omega-3. Identification of micronutrient deficiency in the first 1000 days of life and timely supplementation proves essential to prevent their long-term consequences.

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.

Risk factors and outcomes of vitamin D deficiency in very preterm infants

BACKGROUND

Vitamin D is essential for bone health and immune system. Vitamin D deficiency (VDD) poses a high-risk to very preterm (VP) infants. This study aimed to evaluate the risk factors associated with VDD in VP infants and its potential clinical outcomes.

METHODS

A retrospective cohort study was conducted on VP infants admitted to the neonatal intensive care unit of a specialized tertiary hospital in Seoul, Republic of Korea, between January 2018 and June 2022. Serum 25-hydroxyvitamin D (25(OH)D) levels and other biochemical parameters were measured between 4 and 6 weeks of age. VDD was defined as a serum 25(OH)D level <20 ng/mL. Prenatal and postnatal risk factors and clinical outcomes were compared between the VDD and non-VDD groups.

RESULTS

Of the 82 VP infants analyzed, 27 (32.9%) were diagnosed with VDD. The VDD group exhibited a significantly longer duration of parenteral nutrition (PN) compared to the non-VDD group (adjusted odds ratio [OR] = 1.12; 95% confidence interval [CI]: 1.008-1.245). Breast milk intake was lower in the VDD group than in the non-VDD group (adjusted OR = 0.976, 95% CI, 0.955-0.999). Notably, calcium levels were significantly lower in the VDD group, while parathyroid hormone levels were significantly higher, compared with the non-VDD group. Additionally, the rickets severity score was higher in the VDD group than in the non-VDD, although the difference was not statistically significant.

CONCLUSIONS

Prolonged PN duration and low breast milk intake significantly increased the risk of VDD in VP infants.

Diagnosis, treatment, and management of rickets: a position statement from the Bone and Mineral Metabolism Group of the Italian Society of Pediatric Endocrinology and Diabetology

Rickets results from impaired mineralization of growing bone due to alterations in calcium and phosphate homeostasis. Clinical signs of rickets are related to the age of the patient, the duration of the disease, and the underlying disorder. The most common signs of rickets are swelling of the wrists, knees or ankles, bowing of the legs (knock-knees, outward bowing, or both) and inability to walk. However, clinical features alone cannot differentiate between the various forms of rickets. Rickets includes a heterogeneous group of acquired and inherited diseases. Nutritional rickets is due to a deficiency of vitamin D, dietary calcium or phosphate. Mutations in genes responsible for vitamin D metabolism or function, the production or breakdown of fibroblast growth factor 23, renal phosphate regulation, or bone mineralization can lead to the hereditary form of rickets. This position paper reviews the relevant literature and presents the expertise of the Bone and Mineral Metabolism Group of the Italian Society of Pediatric Endocrinology and Diabetology (SIEDP). The aim of this document is to provide practical guidance to specialists and healthcare professionals on the main criteria for diagnosis, treatment, and management of patients with rickets. The various forms of rickets are discussed, and detailed references for the discussion of each form are provided. Algorithms to guide the diagnostic approach and recommendations to manage patients with rare forms of hereditary rickets are proposed.

Proactive Use of a Human Milk Fat Modular in the Neonatal Intensive Care Unit: A Standardized Feeding Protocol

An exclusive human milk diet (EHMD) and standardized feeding protocols are two critical methods for safely feeding very low birth weight (VLBW) infants. Our institution initiated a standardized feeding protocol for all VLBW infants in 2018. In this protocol, a human milk fat modular was used only reactively when an infant had poor weight gain, fluid restriction, or hypoglycemia. As part of our NICU quality improvement program, internal utilization review data revealed a potential opportunity to improve growth and reduce costs. While maintaining the EHMD, a simple feeding guideline process change could provide cost savings without sacrificing caloric density or growth. We examined this process change in pre-post cohorts of VLBW infants.

METHODS

Our revised feeding protocol, established in October 2021, called for a human milk fat modular (Prolact CR) to be added to all infant feeding when parenteral nutrition (PN) and lipids were discontinued. The human milk fat modular concentration is 4 mL per 100 mL feed, providing approximately an additional 2 kcal/oz. We tracked data to compare (1) the use of the human milk fat modular, (2) the use of the human milk +8 fortifier, (3) overall growth before and after feeding protocol changes, and (4) cost differences between protocols.

RESULTS

Thirty-six VLBW infants were followed prospectively upon the introduction of the revised feeding protocol. In the revised era, the need for human milk +8 fortifier decreased from 43% to 14%. The decrease in the cost of a more costly fortifier provided a cost savings of USD 2967.78 on average per infant. Overall growth improved from birth to discharge, with severe malnutrition declining from 3.3% to 2.7% and moderate malnutrition declining from 37% to 8%.

CONCLUSIONS

With the proactive use of a human milk fat modular in a standardized feeding protocol, our VLBW infants showed improved growth, lower malnutrition rates, and decreased use of higher caloric fortifiers.

The role of nutrition in analysis of risk factors and short-term outcomes for late-onset necrotizing enterocolitis among very preterm infants: a nationwide, multicenter study in China

BACKGROUND

Necrotizing enterocolitis (NEC) is a serious gastrointestinal disease, primarily affects preterm newborns and occurs after 7 days of life (late-onset NEC, LO-NEC). Unfortunately, over the past several decades, not much progress has been made in its treatment or prevention. This study aimed to analyze the risk factors for LO-NEC, and the impact of LO-NEC on short-term outcomes in very preterm infants (VPIs) with a focus on nutrition and different onset times.

METHOD

Clinical data of VPIs were retrospectively collected from 28 hospitals in seven different regions of China from September 2019 to December 2020. A total of 2509 enrolled VPIs were divided into 2 groups: the LO-NEC group and non-LO-NEC group. The LO-NEC group was divided into 2 subgroups based on the onset time: LO-NEC occurring between 8 ~ 14d group and LO-NEC occurring after 14d group. Clinical characteristics, nutritional status, and the short-term clinical outcomes were analyzed and compared among these groups.

RESULTS

Compared with the non-LO-NEC group, the LO-NEC group had a higher proportion of anemia, blood transfusion, and invasive mechanical ventilation (IMV) treatments before NEC; the LO-NEC group infants had a longer fasting time, required longer duration to achieve the target total caloric intake (110 kcal/kg) and regain birthweight, and showed slower weight growth velocity; the cumulative dose of the medium-chain and long-chain triglyceride (MCT/LCT) emulsion intake in the first week after birth was higher and breastfeeding rate was lower. Additionally, similar results including a higher proportion of IMV, lower breastfeeding rate, more MCT/LCT emulsion intake, slower growth velocity were also found in the LO-NEC group occurring between 8 ~ 14d when compared to the LO-NEC group occurring after 14 d (all (P < 0.05). After adjustment for the confounding factors, high proportion of breastfeeding were identified as protective factors and long fasting time before NEC were identified as risk factors for LO-NEC; early feeding were identified as protective factors and low gestational age, grade III ~ IV neonatal respiratory distress syndrome (NRDS), high accumulation of the MCT/LCT emulsion in the first week were identified as risk factors for LO-NEC occurring between 8 ~ 14d. Logistic regression analysis showed that LO-NEC was a risk factor for late-onset sepsis, parenteral nutrition-associated cholestasis, metabolic bone disease of prematurity, and extrauterine growth retardation.

CONCLUSION

Actively preventing premature birth, standardizing the treatment of grade III ~ IV NRDS, and optimizing enteral and parenteral nutrition strategies may help reduce the risk of LO-NEC, especially those occurring between 8 ~ 14d, which may further ameliorate the short-term clinical outcome of VPIs.

TRIAL REGISTRATION

ChiCTR1900023418 (26/05/2019).

Effect of early preventive supplementation with calcium and phosphorus on metabolic bone disease in premature infants

OBJECTIVE

The objective was to study the effect of early preventive calcium and phosphorus supplementation on metabolic bone disease in preterm infants.

METHODS

A retrospective analysis of 234 preterm infants with a gestational age < 32 weeks or birth weight < 1500 g who were hospitalized in the Neonatology Department of the Second Hospital of Shandong University from 01.2018 to 12.2020 was conducted. One hundred thirty-two premature infants hospitalized from 01.2018 to 06.2019 did not receive prophylactic calcium and phosphorus supplementation in the early postnatal period. These infants received calcium or phosphorus supplementation at the time of hypocalcaemia or hypophosphatemia diagnosis. One hundred two premature infants hospitalized from 07.2019 to 12.2020 received early preventive calcium and phosphorus supplementation after birth. The levels of serum calcium and phosphorus, alkaline phosphatase, 25-hydroxyvitamin D, calcitonin, and parathyroid hormone at different time points and growth indicators at six months of age were compared between the two groups of infants. The number of cases of metabolic bone disease and fracture between the two groups was compared.

RESULTS

1) A total of 12 infants (5.13%) among the 234 preterm infants were diagnosed with metabolic bone disease, including 2 (1.96%) in the prophylactic supplementation group and 10 (7.58%) in the nonprophylactic supplementation group. Fractures occurred in 3 premature infants (25.0%) with metabolic bone disease, all of whom were in the group that did not receive prophylactic supplementation. 2) There was no significant difference in serum calcium and calcitonin levels between the two groups. The levels of serum phosphorus and 25 hydroxyvitamin D in the prophylactic supplementation group were higher than those in the nonprophylactic supplementation group (P < 0.05). In comparison, alkaline phosphatase and parathyroid hormone levels were lower in the prophylactic supplementation group than in the nonprophylactic supplementation group (P < 0.05). Preterm infants in the prophylactic supplementation group had higher weight, length, head circumference, and bone density values than those in the nonprophylactic supplementation group (P < 0.05).

CONCLUSION

Preventive supplementation with calcium and phosphorus after birth can effectively improve calcium and phosphorus metabolism, and reduce the incidence of metabolic bone disease and fractures in premature infants. This can be further publicized and used clinically.

Reducing Osteopenia of Prematurity-related Fractures in a Level IV NICU: A Quality Improvement Initiative

Background

Osteopenia of prematurity (OOP) is often a silent disease in the neonatal intensive care unit (NICU). Despite its association with increased neonatal morbidity, such as fractures, wide variation exists in screening, diagnostic, and management practices. We sought to decrease the rate of OOP-related fractures in our level IV NICU by 20% within 1 year.

Methods

A multidisciplinary quality improvement team identified inconsistent screening, diagnosis, and management of OOP, as well as handling of at-risk patients, as primary drivers for OOP-related fractures. Using the model for improvement, we implemented sequential interventions, including screening, diagnosis, and a management algorithm as a "handle-with-care" bundle in infants at risk for fractures.

Results

194 at-risk infants were included, 59 of whom had OOP. There was special cause variation in OOP-related fractures, with a reduction from 0.43 per 1000 patient days to 0.06 per 1000 patient days with our interventions. There was also an improvement in days between fractures from 62 to 337 days. We achieved these improvements despite a similar prevalence of OOP throughout the initiative. We showed special cause variation with increased patients between missed OOP documentation and improved collection of OOP screening laboratories at 4 weeks of life without increased blood testing.

Conclusion

A multidisciplinary team approach with standardized OOP screening, diagnosis, and management guidelines, including a handle-with-care bundle, reduces OOP-related fractures in a level IV NICU.

Metabolic bone disease of prematurity screening and individualized enteral mineral supplementation in high-risk neonates: a quality improvement initiative

OBJECTIVE

Prompted by an alarmingly low screening rate for metabolic bone disease of prematurity (MBDP), we aimed to increase MBDP screening with serum calcium, phosphorous, and alkaline phosphatase at four to six weeks of life in infants born at <1500 g and <32 gestational weeks from a baseline of 27.37% to 90% within one year.

STUDY DESIGN

We used the Institute for Healthcare Improvement's Model for Improvement as a framework. A key driver diagram informed the interventions which were carried out through four Plan-Do-Study-Act cycles.

RESULTS

There were 129 and 130 neonates in the pre-intervention baseline group and post-intervention MBDP bundle group, respectively. MBDP bundled primary screening rates increased from 27.37% to 95.56% (p < 0.001). Furthermore, 20% of infants had an individualized change in their enteral mineral supplementation after the initiative.

CONCLUSIONS

An interdisciplinary team-based quality improvement approach was effective in altering clinical practice to improve screening and subsequent treatment for 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.

Neurodevelopment Outcomes in Very-Low-Birth-Weight Infants with Metabolic Bone Disease at 2 Years of Age

Metabolic bone disease (MBD) predominantly affects preterm infants, particularly very-low-birth-weight (VLBW) infants weighing <1500 g. However, there are limited reports on MBD and neurodevelopmental outcomes. This study aimed to analyze the risk factors for MBD and understand its impact on neurodevelopmental outcomes at 2 years of corrected age. Overall, 749 VLBW infants weighing <1350 g at birth were enrolled. Exclusion criteria were major congenital abnormalities, chromosomal abnormalities, and loss of follow-up on the Bayley Scales of Infant Development, Third Edition (BSID-III) test at 24 months of corrected age. Infants were retrospectively assessed by a trained case manager using the BSID-III test at 6, 12, and 24 months old. Infants were categorized as with or without MBD according to radiographic signs. Of those enrolled, 97 VLBW infants were diagnosed with MBD, compared to 362 VLBW infants without MBD. The proportion of infants that completed three follow-ups was 86%. At the assessment at 2 years of age, infants with MBD had lower and more significant differences in motor, language, and cognitive composites. MBD is associated with poor neurodevelopmental outcomes in cognitive, motor, and language composites for VLBW infants at 24 months of corrected age.

Use of Total Parenteral Nutrition (TPN) as a Vehicle for Drug Delivery

Total Parenteral Nutrition (TPN) is a method of providing nutrients directly into the bloodstream for individuals who are unable to meet their nutritional needs through the normal digestive process or gastrointestinal system. It provides macronutrients and micronutrients in a single container, reducing handling and contamination risks and making it more cost-effective. TPN has the potential to be used as a drug delivery system, with applications in combination therapies, personalized medicine, and integrating advanced technologies. It can enhance drug dosage precision and provide nutritional assistance, potentially reducing hospitalization and improving patient outcomes. However, implementing new applications requires thorough testing and regulatory approval. TPN could be particularly useful in pediatric and geriatric care and could also contribute to global health by combating malnutrition in areas with limited medical resources. Healthcare professionals prepare a sterile solution tailored to each patient's nutritional needs, and administration involves a central venous catheter. However, the simultaneous administration of medications with PN admixtures can result in pharmacological incompatibility, which can impact the stability of the oil-in-water system. The European Society for Clinical Nutrition and Metabolism and the American Society for Parenteral and Enteral Nutrition recommendations advise against including non-nutrient drugs in PN admixtures due to safety concerns. This review focuses on the utilization of Total Parenteral Nutrition (TPN) as a method for delivering drugs. It discusses the benefits and difficulties associated with its commercial application and offers suggestions for future research endeavors.

Quantifying Bone Strength Deficits in Young Adults Born Extremely Preterm or Extremely Low Birth Weight

The long-term bone health of young adults born extremely preterm (EP; <28 weeks' gestation) or extremely low birth weight (ELBW; <1000 g birth weight) in the post-surfactant era (since the early 1990s) is unclear. This study investigated their bone structure and estimated bone strength using peripheral quantitative computed tomography (pQCT)-based finite element modeling (pQCT-FEM). Results using this technique have been associated with bone fragility in several clinical settings. Participants comprised 161 EP/ELBW survivors (46.0% male) and 122 contemporaneous term-born (44.3% male), normal birth weight controls born in Victoria, Australia, during 1991-1992. At age 25 years, participants underwent pQCT at 4% and 66% of tibia and radius length, which was analyzed using pQCT-FEM. Groups were compared using linear regression and adjusted for height and weight. An interaction term between group and sex was added to assess group differences between sexes. Parameters measured included compressive stiffness (kcomp ), torsional stiffness (ktorsion ), and bending stiffness (kbend ). EP/ELBW survivors were shorter than the controls, but their weights were similar. Several unadjusted tibial pQCT-FEM parameters were lower in the EP/ELBW group. Height- and weight-adjusted ktorsion at 66% tibia remained lower in EP/ELBW (mean difference [95% confidence interval] -180 [-352, -8] Nm/deg). The evidence for group differences in ktorsion and kbend at 66% tibia was stronger among males than females (pinteractions  <0.05). There was little evidence for group differences in adjusted radial models. Lower height- and weight-adjusted pQCT-FEM measures in EP/ELBW compared with controls suggest a clinically relevant increase in predicted long-term fracture risk in EP/ELBW survivors, particularly males. Future pQCT-FEM studies should utilize the tibial pQCT images because of the greater variability in the radius possibly related to lower measurement precision. © 2023 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

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.

Artificial placenta support of extremely preterm ovine fetuses at the border of viability for up to 336 hours with maintenance of systemic circulation but reduced somatic and organ growth

Introduction: Artificial placenta therapy (APT) is an experimental life support system to improve outcomes for extremely preterm infants (EPI) less than 1,000 g by obviating the need for pulmonary gas exchange. There are presently no long-term survival data for EPI supported with APT. To address this, we aimed to maintain 95d-GA (GA; term-150d) sheep fetuses for up to 2 weeks using our APT system. Methods: Pregnant ewes (n = 6) carrying singleton fetuses underwent surgical delivery at 95d GA. Fetuses were adapted to APT and maintained for up to 2 weeks with constant monitoring of key physiological parameters and extensive time-course blood and urine sampling, and ultrasound assessments. Six age-matched in-utero fetuses served as controls. Data were tested for group differences with ANOVA. Results: Six APT Group fetuses (100%) were adapted to APT successfully. The mean BW at the initiation of APT was 656 ± 42 g. Mean survival was 250 ± 72 h (Max 336 h) with systemic circulation and key physiological parameters maintained mostly within normal ranges. APT fetuses had active movements and urine output constantly exceeded infusion volume over the experiment. At delivery, there were no differences in BW (with edema in three APT group animals), brain weight, or femur length between APT and in-utero Control animals. Organ weights and humerus lengths were significantly reduced in the APT group (p < 0.05). Albumin, IGF-1, and phosphorus were significantly decreased in the APT group (p < 0.05). No cases of positive blood culture were detected. Conclusion: We report the longest use of APT to maintain extremely preterm fetuses to date. Fetal systemic circulation was maintained without infection, but growth was abnormal. This achievement suggests a need to focus not only on cardiovascular stability and health but also on the optimization of fetal growth and organ development. This new challenge will need to be overcome prior to the clinical translation of this technology.

Prenatal and Neonatal Bone Health: Updated Review on Early Identification of Newborns at High Risk for Osteopenia

Bone health starts with maternal health and nutrition, which influences bone mass and density already in utero. The mechanisms underlying the effect of the intrauterine environment on bone health are partly unknown but certainly include the 'foetal programming' of oxidative stress and endocrine systems, which influence later skeletal growth and development. With this narrative review, we describe the current evidence for identifying patients with risk factors for developing osteopenia, today's management of these populations, and screening and prevention programs based on gestational age, weight, and morbidity. Challenges for bone health prevention include the need for new technologies that are specific and applicable to pregnant women, the foetus, and, later, the newborn. Radiofrequency ultrasound spectrometry (REMS) has proven to be a useful tool in the assessment of bone mineral density (BMD) in pregnant women. Few studies have reported that transmission ultrasound can also be used to assess BMD in newborns. The advantages of this technology in the foetus and newborn are the absence of ionising radiation, ease of use, and, above all, the possibility of performing longitudinal studies from intrauterine to extrauterine life. The use of these technologies already in the intrauterine period could help prevent associated diseases, such as osteoporosis and osteopenia, which are characterised by a reduction in bone mass and degeneration of bone structure and lead to an increased risk of fractures in adulthood with considerable social repercussions for the related direct and indirect costs.

"Ping-pong" fracture: An exclusive entity of neonates and infants? A case analysis and literature review

Background

"Ping-pong" fractures are a type of depressed fracture in which there is no rupture of the inner or outer table of the skull. It is produced by incomplete bone mineralization. Its appearance is frequent during neonatal and infant ages and is extremely rare outside of these age periods. The objective of this article is to present the case of a 16-year-old patient who presented a "ping-pong" fracture after a traumatic brain injury (TBI) and discuss the underlying physiopathogenesis of these types of fractures.

Case Description

A 16-year-old patient presented to the emergency department with a TBI, referring headaches and nausea. Non-contrast brain computed tomography displayed a left parietal "ping-pong" fracture. Laboratory tests showed hypocalcemia, subsequently diagnosing hypoparathyroidism. The patient remained under observation for 48 h. He was managed conservatively and started on calcium carbonate and vitamin D supplements with a favorable evolution. Hospital discharge was granted with TBI discharge instructions and warning signs.

Conclusion

The age of presentation of our case was atypical, according to the reported literature. When faced with a "ping-pong" fracture outside of an early age, underlying bone pathologies must be ruled out, which could potentially generate incomplete bone mineralization of the skull.

Establishment of a nomogram model for predicting metabolic bone disease in preterm infants: A case‒control study

OBJECTIVE

To investigate risk factors for metabolic bone disease (MBD) in preterm infants and establish a nomogram model for predicting MBD risk.

METHODS

A total of 1104 preterm infants were enrolled, among whom 809 were included in the modelling set and 295 were included in the validation set. The modelling set was divided into MBD (n = 185) and non-MBD (n = 624) groups. A multivariate logistic regression analysis was used to investigate the independent risk factors for MBD. R software was used to plot the nomogram model, which was then validated by the data of the validation set. Receiver operating characteristic (ROC) and calibration curves were used to evaluate the nomogram model's performance, and the clinical decision curve was used to assess the clinical practicability of the model.

RESULTS

Gestational age, time of trophic feeding initiation, parenteral nutrition duration, necrotizing enterocolitis, bronchopulmonary dysplasia, cholestasis and sepsis were independent risk factors for MBD in preterm infants (P < 0.05). The ROC curve of the modelling set had an area under the curve (AUC) of 0.801; the risk prediction value of 0.196 corresponding to the maximum Youden index was the best value, and the prediction critical value was 125 points. The ROC curve of the validation set had an AUC of 0.854. The calibration curve analysis showed good accuracy and consistency between the model's predicted and actual values.

CONCLUSIONS

The nomogram model provides an efficient tool for the early assessment of MBD risk. Preterm infants with scores ≥ 125 should receive close attention and interventions in the early stage.

WHAT IS KNOWN

• The incidence and severity of MBD are inversely proportional to gestational age and birth weight. Bone loss can lead to prolonged hospital stay, ventilator dependence, pathological fractures and short stature.

WHAT IS NEW

• Gestational age, time of trophic feeding initiation, parenteral nutrition duration, necrotizing enterocolitis, bronchopulmonary dysplasia, cholestasis and sepsis were independent risk factors for MBD in preterm infants. The nomogram model provides an efficient tool for the early assessment of MBD risk.

Risk Factors and Clinical Characteristics of Metabolic Bone Disease of Prematurity

OBJECTIVE

 The study aimed to analyze the risk factors and clinical features of metabolic bone disease of prematurity (MBDP) in premature infants compared with infants of similar gestational age and birth weight without MBDP.

STUDY DESIGN

 This retrospective case-control study was performed by comparing 81 cases of MBDP with 63 controls to identify potential risk factors. Premature infants with a gestational age ≤33 weeks and birth weight <1,500 g were included. Medical records were examined in terms of maternal conditions, potential risk factors, and clinical characteristics.

RESULTS

 Bone fractures and invasive ventilator dependence were the most common clinical features of MBDP. Duration of invasive ventilation and total mechanical ventilation days, necrotizing enterocolitis, corticosteroid use, anticonvulsive drug use, duration of dexamethasone and caffeine use, total parenteral nutrition, and length of hospitalization were significantly higher in neonates with MBDP (p < 0.05). Breastfed neonates and those receiving human milk fortifier had a lower incidence of MBDP than those premature formula or mixed feeding (p < 0.05). Anticonvulsive drug use (odds ratio: 2.935; 95% confidence interval: 1.265-6.810) was identified as a risk factor for MBDP at multiple regression analysis.

CONCLUSION

 Our results show that anticonvulsive drug use is a significant risk factor for the development of MBDP. If long-term use is not required, anticonvulsive drugs should be stopped as soon as possible. Further studies involving patients with MBDP are required to determine the risk factors and clinical features.

KEY POINTS

· MBDP is a multifactorial disorder.. · Anticonvulsive drug use is an important risk factor for the development of MBDP.. · Bone fractures and invasive ventilator dependence are the most common clinical features of MBDP..

Diagnostic markers of metabolic bone disease of prematurity in preterm infants

Due to the higher birth rate of preterm infants and improvements in their management, metabolic bone disease of prematurity (MBDP) has a high incidence and is attracting attention. However, clear indicators for the early diagnosis of MBDP are lacking. We aimed to explore simple and feasible early warning indicators for diagnosing MBDP. Our study collected case data of premature infants from two medical centers in Chongqing from January 2020 to February 2022. According to the inclusion and exclusion criteria, data from 136 cases were collected. The correlation between 14 variables in each case and the occurrence of MBDP was analyzed. According to area under the receiver operating characteristic curve (AUROC) analysis, the best cutoff value for each variable was determined. Potential predictors were selected, and Least Absolute Shrinkage and Selection Operator (LASSO) regression analysis was used to establish the association of two models with MBDP, whose results were used to develop a diagnostic nomogram. Furthermore, a model decision curve was analyzed. Four predictors were selected from 14 clinical variables by LASSO regression, and Model I was established, including the following characteristics: height (>36 cm), head circumference (≤29.49 cm), total serum calcium (Ca) (>2.13 mmol/L), and alkaline phosphatase (ALP) (>344 U/L) levels. A single predictor, the ALP level (>344 U/L), was used to establish Model II. The AUROC values of the two models were 0.959 for Model I and 0.929 for Model II. In conclusion, in this study, two diagnostic models of MBDP were developed using four combinations of predictors and ALP as a single predictor. Both models showed good sensitivity and specificity for the early diagnosis of metabolic bone disease (MBD), and an ALP level of 344 U/L was defined as a simple and effective diagnostic threshold. In future studies, using larger samples, diagnostic threshold values of ALP for premature infants of different ages should be established, and internal and external validations are needed to improve the adaptability of the current model.

Individualized Fortification Based on Measured Macronutrient Content of Human Milk Improves Growth and Body Composition in Infants Born Less than 33 Weeks: A Mixed-Cohort Study

The optimal method for human milk (HM) fortification has not yet been determined. This study assessed whether fortification relying on measured HM macronutrient content (Miris AB analyzer, Upsala, Sweden) composition is superior to fortification based on assumed HM macronutrient content, to optimize the nutrition support, growth, and body composition in infants born at <33 weeks' gestation. In a mixed-cohort study, 57 infants fed fortified HM based on its measured content were compared with 58 infants fed fortified HM based on its assumed content, for a median of 28 and 23 exposure days, respectively. The ESPGHAN 2010 guidelines for preterm enteral nutrition were followed. Growth assessment was based on body weight, length, and head circumference Δ z-scores, and the respective growth velocities until discharge. Body composition was assessed using air displacement plethysmography. Fortification based on measured HM content provided significantly higher energy, fat, and carbohydrate intakes, although with a lower protein intake in infants weighing ≥ 1 kg and lower protein-to-energy ratio in infants weighing < 1 kg. Infants fed fortified HM based on its measured content were discharged with significantly better weight gain, length, and head growth. These infants had significantly lower adiposity and greater lean mass near term-equivalent age, despite receiving higher in-hospital energy and fat intakes, with a mean fat intake higher than the maximum recommended and a median protein-to-energy ratio intake (in infants weighing < 1 kg) lower than the minimum recommended.

Early elevated alkaline phosphatase as a surrogate biomarker of ongoing metabolic bone disease of prematurity

Very low birth weight (VLBW) neonates present a high risk of metabolic bone disease (MBD). Our main objective was to determine the easiest way to make an early diagnosis of this disease by identifying surrogate biomarkers before any radiological signs occurred. We conducted in our NICU a 6-month observational prospective study, with inclusion of all singleton VLBW neonates. We collected clinical and biological data, and nutritional intakes during hospitalization. We defined biological MBD (bMBD) as alkaline phosphatase (ALP) levels superior to 600 UI/L at day of life 30 (DOL30) and performed a case-control analysis. Nine out of 30 patients (30%) exhibited bMBD. All have extremely low birth weight and were significantly younger in gestational age (GA) and smaller at birth. There was no statistically significant difference in nutritional intake between bMBD and control groups. In the bMBD group, phosphatemia was lower since DOL3. ALP was already significantly higher at DOL15, and way beyond normal range.

CONCLUSIONS

Our results showed that even the strict respect of nutritional guidelines cannot completely prevent bMBD in high-risk patients and suggest that an early screening from DOL15, with ALP levels greater than 500 UI/L, could be sufficient for detection of upcoming MBD.

WHAT IS KNOWN

• Metabolic bone disease of prematurity (MBD) definition is not consensual, but biological changes appear earlier than radiological signs of rickets. • MBD management relies on biological evidence. Treatment is based on phosphate and/or calcium and calcitriol supplementation.

WHAT IS NEW

• Studying phosphocalcic biological assessment in very low birth weight neonates, we showed respect of nutritional guidelines could not protect from biological MBD. • Increase in alkaline phosphatase (ALP), about 500 UI/l at day of life 15, could be a biomarker of MBD with no need of X-ray evaluation and sufficient to begin a treatment to prevent osteopenia.

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.

Artificial Neural Network Modeling to Predict Neonatal Metabolic Bone Disease in the Prenatal and Postnatal Periods

Importance

Early recognition of metabolic bone disease (MBD) in infants is necessary but difficult; an appropriate tool to screen infants at risk of developing MBD is needed.

Objectives

To develop a predictive model for neonates at risk for MBD in the prenatal and postnatal periods and detect the pivotal exposed factors in each period.

Design, Setting, and Participants

A diagnostic study was conducted from January 1, 2012, to December 31, 2021, in Shanghai, China. A total of 10 801 pregnant women (singleton pregnancy, followed up until 1 month after parturition) and their infants (n = 10 801) were included. An artificial neural network (ANN) framework was used to build 5 predictive models with different exposures from prenatal to postnatal periods. The receiver operating characteristic curve was used to evaluate the model performance. The importance of each feature was examined and ranked.

Results

Of the 10 801 Chinese women who participated in the study (mean [SD] age, 29.7 [3.9] years), 7104 (65.8%) were local residents, 1001 (9.3%) had uterine scarring, and 138 (1.3%) gave birth to an infant with MBD. Among the 5 ANN models, model 1 (significant prenatal and postnatal factors) showed the highest AUC of 0.981 (95% CI, 0.970-0.992), followed by model 5 (postnatal factors; AUC, 0.977; 95% CI, 0.966-0.988), model 4 (all prenatal factors; AUC, 0.850; 95% CI, 0.785-0.915), model 3 (gestational complications or comorbidities and medication use; AUC, 0.808; 95% CI, 0.726-0.891), and model 2 (maternal nutritional conditions; AUC, 0.647; 95% CI, 0.571-0.723). Birth weight, maternal age at pregnancy, and neonatal disorders (anemia, respiratory distress syndrome, and septicemia) were the most important model 1 characteristics for predicting infants at risk of MBD; among these characteristics, extremely low birth weight (importance, 50.5%) was the most powerful factor. The use of magnesium sulfate during pregnancy (model 4: importance, 21.2%) was the most significant predictor of MBD risk in the prenatal period.

Conclusions and Relevance

In this diagnostic study, ANN appeared to be a simple and efficient tool for identifying neonates at risk for MBD. Combining prenatal and postnatal factors or using postnatal exposures alone provided the most precise prediction. Extremely low birth weight was the most significant predictive factor, whereas magnesium sulfate use during pregnancy could be an important bellwether for MBD before delivery.

Dilemmas in human milk fortification

Fortification of human milk is the standard of care for very low birth weight (VLBW) infants and is required to support adequate postnatal growth and development. Achieving adequate growth velocity and preventing growth faltering is critical for the developing neonatal brain and optimizing long-term neurodevelopmental outcomes. Mother's milk is the gold standard nutrition to feed preterm infants, however, it does not provide the nutrients needed to support the growth of VLBW infants. After the decision is made to use mother's milk (if available) or alternatively, donor human milk, many dilemmas exist with regards to additional treatment decisions surrounding the type of fortification to use, when to fortify, and the duration of fortification. In this article, we will review the differences in mother's milk compared to donor milk, the different types of human milk fortifiers, the optimal timing of fortification, and discuss when to discontinue human milk fortification.

Tibial quantitative ultrasound compared to dual-energy X-ray absorptiometry in preterm infants

OBJECTIVE

The gold standard for diagnosing metabolic bone disease in pediatrics is dual-energy x-ray absorptiometry (DXA). Bone quantitative ultrasound (QUS) has increasing applications. This study compared the relationship of DXA to QUS in preterm infants.

DESIGN

Prospective observational study of preterm infants ≤32 weeks gestation or ≤1800 grams at birth. DXA scans measuring bone mineral content (BMC) and tibial QUS scans measuring bone speed of sound (SOS) were obtained near term gestation.

RESULTS

41 infants had bone scans at mean corrected gestation 37.7 ± 2.1 weeks. BMC and SOS showed weak inverse correlation (R² 0.163, p < 0.01). BMC and SOS correlated with parameters at corrected gestational age at the time of the bone scans (p < 0.05-0.001). SOS correlated with birth gestational age (p < 0.001), not BMC.

CONCLUSIONS

A statistically significant weak inverse correlation between DXA and QUS was observed. QUS may have advantages over DXA.

Vitamin D deficiency in low-birth-weight infants in Uganda; a cross sectional study

Background

Vitamin D deficiency affects 7–86% of infants globally and results in recurrent infections, impaired growth and nutritional rickets. Low-birth-weight infants in Uganda are at risk of vitamin D deficiency due to limited sunlight exposure and dependence on breastmilk. We aimed to determine the prevalence and factors associated with vitamin D deficiency among low-birth-weight infants aged 6 weeks to 6 months at Mulago national referral hospital in Uganda.

Methods

We conducted a cross-sectional study at Mulago Hospital between September 2016 and March 2017. We enrolled infants born with low birth weight between six weeks and six months whose mothers were available and willing to provide informed consent. Upon obtaining informed consent, we administered a structured questionnaire and performed a physical examination on the participants. Blood was drawn for calcium, phosphorus and vitamin D estimation. We measured serum 25 hydroxy vitamin D (25(OH)D) using the electrochemiluminescence method. Vitamin D deficiency and insufficiency were defined as (25(OH)D) < 20ng/ml and from 20ng/ml to <30 ng/ml respectively. To determine factors associated with vitamin D deficiency, we fit multivariable logistic regression models with exposure factors determined a priori. Data were analysed using Stata version 14.

Results

We enrolled 297 participants, 49.2% (167/297) of whom were males. The median infant age was nine weeks (interquartile range 7–13). All infants had less than one hour of sunlight exposure and over 90.6% (269/297) had received multivitamin supplements containing vitamin D. The prevalence of vitamin D deficiency was 12.1% (36/297): 95% CI (8.9%-16.4%). The prevalence of vitamin D insufficiency was 19.9% (59/297): 95% CI (15.7%-24.8%). Boys had higher odds of vitamin D deficiency compared to girls [adjusted odds ratio 2.8: 95% CI 1.3–6.1].

Conclusion

Vitamin D deficiency was 12.1% among low-birth-weight infants in Uganda although almost all of them had received multivitamin supplements containing vitamin D. We recommend that more studies are done in low-birth-weight infants to assess the risk factors for vitamin D in these population in Uganda.

The impact of an early intervention home-based program on body composition in preterm-born preschoolers with very low birth weight

Background and aims

Early child interventions focused on the family prevented neurodevelopmental and behavioral delays and can provide more knowledge regarding responsive feeding, thus creating learning opportunities to promote better quality nutrition and preventing failure to thrive. The aim is to verify the impact of a continuous program of early home-based intervention on the body composition of preschool infants who were born preterm with very low birth weight (VLBW).

Methods

This is a longitudinal analysis from a randomized controlled trial, including VLBW preterm children, born in a tertiary hospital in Southern Brazil and followed up at the high-risk institutional ambulatory clinic. Participants were divided into the intervention group (IG): skin-to-skin care with the mother (kangaroo care), breastfeeding policy, and tactile-kinesthetic stimulation by mothers until hospital discharge. Subsequently, they received a program of early intervention with orientation and a total of 10 home visits, independently from the standard evaluation and care that was performed following the 18 months after birth; conventional group (CG): standard care according to the routine of the newborn intensive care unit (NICU), which includes kangaroo care, and attending to their needs in the follow-up program. Body composition estimation was performed using bioelectrical impedance analyses (BIA), and physical activity and feeding practices questionnaires were evaluated at preschool age, as well as anthropometric measurements and biochemical analysis.

Results

Data of 41 children at 4.6 ± 0.5 years old were evaluated (CG n = 21 and IG n = 20). Body weight, height, body mass index, waist and arm circumferences, and triceps and subscapular skinfold did not differ between groups. The IG presented higher segmented fat-free mass (FFM) when compared to the CG (right arm FFM: 0.74 vs. 0.65 kg, p = 0.040; trunk FFM: 6.86 vs. 6.09 kg, p = 0.04; right leg FFM: 1.91 vs. 1.73 kg, p = 0.063). Interaction analyses showed that segmented FFM and FFM Index were associated with higher iron content in the IG. In the CG, interaction analyses showed that increased visceral fat area was associated with higher insulin resistance index.

Conclusion

An early intervention protocol from NICU to a home-based program performed by the mothers of VLBW preterm children of low-income families presents a small effect on FFM.

Postpartum Maternal Emotional Disorders and the Physical Health of Mother and Child

Purpose

The purpose of this study is to identify the relationships between postpartum emotional manifestations and various neonatal variables, as well as variables within this category, in the context of hospitalization together after birth.

Patients and Methods

Between 1 March 2020 and 1 September 2020, a cross-sectional research design was used including mother–child couples (112 mothers, 121 newborns - 13 twins/triplets).

Results

Using a t-test for independent samples, we observed: a) the symptoms of depression were more severe in mothers of newborns hospitalized in neonatal intensive care units (NICUs) [t(110) = 4.334)], provided oxygen therapy [t(109.99) = 3.162], born prematurely [t(110) = 3.157], or with adjustment disorders [t(109) = −2.947] (p < 0.01); b) a similar, for anxiety as a state [t(82.38) = 5.251], t(107.29) = 4.523, t(110) = 3.416, t(109) = −3.268, p < 0.01], and as a trait was more common [t(80.79) = 4.501, t(108.790) = 4.669, t(109) = −3.268, p < 0.001] compared to other mothers. Using Pearson’s test (p < 0.001), several very strong correlations were observed between neonatal variables, including number (no.) of days of hospitalization with birth weight (BW) (r = −0.802), head circumference (HC) (r = −0.822), and gestational age (GA) (r = −0.800) and the mother’s postpartum anxiety as a state/trait (r = 0.770). Using Poisson regression, it was observed that anxiety as a state (Λ = 0.020, z = 4.029, p < 0.001) and as a trait (Λ = 0.800, z = 6.160, p < 0.001) stimulated the intensity of symptoms of postpartum depression (optimal models).

Conclusion

Postpartum maternal psychological manifestations were associated with NICU hospitalization, pathology, and some neonatal therapies. We also noticed, that the duration of hospitalization, BW, HC, and GA, were correlated with maternal emotional disorders. Results will facilitate future optimization of birth management and postnatal care.

Don't Forget the Bones: Incidence and Risk Factors of Metabolic Bone Disease in a Cohort of Preterm Infants

Metabolic bone disease of prematurity (MBD) is a condition of reduced bone mineral content (BMC) compared to that expected for gestational age (GA). Preterm birth interrupts the physiological process of calcium (Ca) and phosphorus (P) deposition that occurs mostly in the third trimester of pregnancy, leading to an inadequate bone mineralization during intrauterine life (IUL). After birth, an insufficient intake of Ca and P carries on this alteration, resulting in overt disease. If MBD is often a self-limited condition, in some cases it could hesitate the permanent alteration of bone structures with growth faltering and failure to wean off mechanical ventilation due to excessive chest wall compliance. Despite advances in neonatal intensive care, MBD is still frequent in preterm infants, with an incidence of 16−23% in very-low-birth-weight (VLBW, birth weight <1500 g) and 40−60% in extremely low-birth-weight (ELBW, birth weight <1000 g) infants. Several risk factors are associated with MBD (e.g., malabsorption syndrome, parenteral nutrition (PN), pulmonary bronchodysplasia (BPD), necrotizing enterocolitis (NEC), and some chronic medications). The aim of this study was to evaluate the rate of MBD in a cohort of VLBWI and the role of some risk factors. We enrolled 238 VLBWIs (107 male). 52 subjects were classified as increased risk (G1) and 186 as standard risk (G2) according to serum alkaline phosphatase (ALP) and phosphorus (P) levels. G1 subjects have lower GA (p < 0.01) and BW (p < 0.001). Moreover, they need longer PN support (p < 0.05) and invasive ventilation (p < 0.01). G1 presented a higher rate of BPD (p = 0.026). At linear regression analysis, BW and PN resulted as independent predictor of increased risk (p = 0.001, p = 0.040, respectively). Preventive strategies are fundamental to prevent chronic alteration in bone structures and to reduce the risk of short stature. Screening for MBD based on serum ALP could be helpful in clinical practice to identify subjects at increased risk.

Osteopenia of prematurity and associated nutritional factors: case-control study

BACKGROUND

Preterm newborn nutrition affects postnatal skeletal growth and bone mineralization, but studies have not yet fully concluded the relationship between nutrition and osteopenia. This study was intended to investigate the impact of nutritional factors on osteopenia in preterm newborns.

METHODS

This is a case-control study with babies born with gestational age ≤ 32 weeks in a high-risk maternity hospital, between 2018 and 2019. The population consisted of 115 newborns, being 46 cases (40%) and 69 controls (60%). Disease outcome was based on serum alkaline phosphatase levels > 900UL/l and hypophosphatemia < 4 mg/dl. Gestational data at birth and clinical and nutritional follow-up data during 8 weeks postnatally were assessed. Variables were assessed using regressive logistic models.

FINDINGS

Preterm infants who were fed pasteurized fresh human milk with acidity ≥ 4 ºDornic are 5.36 times more likely to develop osteopenia (p = 0.035). Higher calcium intake, compared to controls, also increased the probability of disease occurrence [OR 1.05 (CI 1.006-1.1); p = 0.025], while the presence of a partner [OR 0.10 (CI 0.02-0.59); p = 0.038] and the shortest time using sedatives [OR 0.89 (CI 0.83-0.98); p = 0.010] were protective factors associated with osteopenia. Extremely low birth weight [OR 5.49 (CI 1.20-25.1); p = 0.028], sepsis [OR 5.71 (CI 1.35-24.2); p = 0.018] and invasive ventilatory support [OR 1.09 (CI 1.03-1.18); p = 0.007] were risk factors.

CONCLUSIONS

Acidity and high calcium intake are the main nutritional factors associated with osteopenia of prematurity. Further studies on the use of human milk with lower acidity, recommendation and nutritional supplementation of calcium should be accomplished to guide prevention strategies in newborns at risk for osteopenia during hospital stay.

Bone mineral density in very low birthweight adults-A sibling study

BACKGROUND

Children and adults born very low birthweight (VLBW, <1500 g) at preterm gestations have lower bone mineral density (BMD) and/or bone mineral content (BMC) than those born at term, but causality remains unknown.

OBJECTIVES

Our aim was to assess BMD and BMC in adults born at VLBW in a sibling comparison setting to account for shared genetic and environmental confounders.

METHODS

We conducted a cohort study of 77 adults born VLBW and 70 same-sex term-born siblings at mean age of 29 years. The primary outcome variables were BMD Z-scores, and BMC, of the femoral neck, lumbar spine, and whole body, measured using dual-energy X-ray absorptiometry. We analysed data by linear mixed models.

RESULTS

The VLBW adults had a 0.25 (95% CI 0.02, 0.47) Z-score unit lower femoral neck BMD, and 0.35 (95% CI 0.16, 0.54) grams lower femoral neck BMC than their term-born siblings, after adjustment for sex, age, and maternal smoking. Additional adjustment for adult body size attenuated the results. Lumbar spine, and whole body BMC were also lower in the VLBW group.

CONCLUSIONS

Individuals born at VLBW had lower BMC values at all three measurement sites, as well as lower femoral neck BMD Z-scores, compared to term-born siblings, partly explained by their smaller adult body size, but the differences were smaller than those reported previously with unrelated controls. This suggests that genetic or environmental confounders explain partly, but not exclusively, the association between preterm VLBW birth and adult bone mineralisation.

Incidence, Risk Factors and Prediction of Secondary Hyperparathyroidism in Preterm Neonates under 32 Weeks’ Gestational Age

In preterm newborns, secondary hyperparathyroidism (HPTH) is an underdiagnosed and undertreated entity. Its detection in the context of metabolic bone mineral disease (MBD) screening programs may be important to guide nutritional treatment. We designed a retrospective cohort study to determine the incidence of HPTH in very premature infants. As secondary objectives, we studied the risk factors, morbidities, and biochemical alterations associated with HPTH. A total of 154 preterm newborns ≤32 weeks gestational age (GA) were included. Of these, 40.3% (n = 62) presented with HPTH. In the multivariate analysis, independent risk factors for HPTH were cesarean section (OR: 4.00; 95% CI: 1.59–10.06), oxygen during resuscitation (OR: 3.43; 95% CI: 1.09–10.81), invasive mechanical ventilation (OR: 3.56; 95% CI: 1.63–7.77) and anemia requiring transfusion (OR: 2.37; 95% CI: 1.01–5.57). Among the analytical variables, serum calcium (OR: 0.53; 95% CI: 0.29–0.97), serum phosphate (OR: 2.01; 95% CI: 1.39–2.92), vitamin D (OR: 0.96; 95% CI: 0.93–1), and the calcium/creatinine ratio in urine (OR: 0.05; 95% CI: 0.01–0.28) were independently associated with HPTH. The simplified predictive model included GA and calcium/creatinine ratio in urine and demonstrated an AUC of 0.828. We concluded that HPTH is a frequent entity among very premature infants and that further studies are required to determine the role of HPTH in MBD and the clinical applicability of prediction models.

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.

Risk factors for metabolic bone disease of prematurity: A meta-analysis

Objective

To investigate the risk factors for metabolic bone disease of prematurity (MBDP), and to provide a reference for the prevention of MBDP.

Methods

The databases including China Biomedical Literature Service System, China National Knowledge Infrastructure, Wanfang Data, and Weipu Periodical Database, PubMed, Web of Science, Embase, Cochrane Library and other databases were searched for studies on the risk factors for MBDP published up to June 18, 2021. RevMan 5.3 and Stata 14.1 software were used to perform a Meta analysis.

Results

A total of 15 articles were included, including 13 case-control studies, 1 current investigation, and 1 retrospective cohort study. There were 1,435 cases in the case group and 2,057 cases in the control group, with a total sample size of 3,492 cases. Meta analysis showed that risk factors for MBDP include birth weight <1000g (OR = 6.62, 95%CI: 2.28–19.25), gestational age <32 weeks (OR = 2.73, 95%CI: 1.07–6.95), septicemia (OR = 2.53, 95%CI: 1.69–3.79), parenteral nutrition time (OR = 4.04, 95%CI: 1.72–9.49), cholestasis (OR = 3.50, 95%CI: 1.49–8.23), intrauterine growth retardation (OR = 6.89, 95%CI: 3.81–12.44), while the birth weight(OR = 0.44, 95%CI: 0.21–0.90) and gestational age (OR = 0.57, 95%CI: 0.44–0.73)are the protective factors of MBDP.

Conclusion

Factors like birth weight <1000g, gestational age <32 weeks, septicemia, parenteral nutrition time, cholestasis, and intrauterine growth retardation may increase the risk of metabolic bone disease of prematurity.

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.

[Expert consensus on the follow-up management of bronchopulmonary dysplasia in preterm infants after discharge]

Bronchopulmonary dysplasia (BPD) is a common chronic lung disease in preterm infants and seriously affects the quality of life of preterm infants. BPD is a life-threatening disease to preterm infants and may lead to serious sequelae including feeding difficulties, recurrent lower respiratory tract infection, airway hyperreactive diseases, growth retardation, and neurodevelopmental delay. In order to further standardize the follow-up management of preterm infants with BPD after discharge, based on related clinical evidence in China and overseas and practice experience, the Neonatal Evidence-Based Medicine Group, Committee of Neonatal Medicine, Cross-Strait Medical and Health Exchange Association, formulated this expert consensus from the aspects of the follow-up and management of respiratory diseases, growth and development, pulmonary hypertension, nerve dysplasia, metabolic bone disease, and vaccination of preterm infants with BPD after discharge.

Macrominerals and Trace Minerals in Commercial Infant Formulas Marketed in Brazil: Compliance With Established Minimum and Maximum Requirements, Label Statements, and Estimated Daily Intake

Infant formulas are the main nutritional source for infants when breastfeeding is not possible or recommended. The daily need for specific nutrients, such as essential minerals, in early stages of a child's life is high because of rapid infant growth and development, which impose metabolic flux increases on these pathways to support growth, physical activity, and defense against infections. In this context, this research aimed to determine macromineral and trace mineral contents in starting (phase 1) and follow-up (phase 2) infant formulas marketed in Brazil (n = 30) by inductively coupled plasma-mass spectrometry, calculate estimated daily intakes, and compare them to reference values regarding adequate intake and tolerable upper intake levels. The highest concentrations of macrominerals were observed in Ca, K, P, and Na, and trace minerals in Fe, Zn, Mn, and Cu. Certain homogeneity only to trace mineral contents was observed when analyzing inter-batch values from same manufacturers. In general, all phase 1 and phase 2 infant formula brands and batches met or exceeded Fe, Zn, Cu, Mo, and Se contents when compared to maximum limits established by Codex Alimentarius. In addition, Zn contents in eight phase 1 and in four phase 2 infant formulas were above the contents established by the tolerable upper intake level for children aged 0–6 and/or 7–12 months, respectively. These findings highlight the need to expand regular infant formula inspection concerning nutritional quality, as some composition aspects of these foods must be improved to follow international guidelines, since ideal requirements for infant formula composition, quality, and safety interfere in child development and adult health.

Comparison of two methods measuring serum alkaline phosphatase in neonates

BACKGROUND

Serum alkaline phosphatase (ALP) is a useful bone turnover marker to diagnose metabolic bone disease in preterm infants. In Japan, serum ALP levels were generally measured using the Japan Society of Clinical Chemistry (JSCC) method. It is problematic that ALP levels measured using the JSCC method tend to be higher in people with blood types B and O regardless of the disease. For international standardization, since 2020, the International Federation of Clinical Chemistry and Laboratory Medicine (IFCC) method has been used as a reference method for ALP measurement instead of the JSCC method. However, no report has investigated the correlation between these two methods in neonates. We therefore aimed to compare the JSCC and IFCC methods and demonstrate a conversion formula in neonates.

METHODS

In this retrospective study, we used a total of 402 samples in 49 preterm and 38 term infants. Serum ALP levels were measured using the JSCC and IFCC methods.

RESULTS

Alkaline phosphatase measured using the JSCC method strongly correlated with that measured using the IFCC method in all blood types in preterm and term infants (P < 0.01 for all).

CONCLUSIONS

We found that the serum ALP levels measured using the IFCC method could be calculated as 0.34 times the ALP levels measured using the JSCC method in preterm and term infants with any blood type: ALP levels (IFCC method) = 0.34 × ALP levels (JSCC method).

Are we undertreating calcium deficiency in metabolic bone disease of prematurity? A case report and review

BACKGROUND

Both calcium (Ca) and phosphorus (P) are needed to prevent and treat metabolic bone disease (MBDP). However, the predominant focus of many treating neonatologists lies in supplementing P and vitamin D. In this report, we describe a VLBW infant with severe MBDP due to inadequately treated calcium deficiency and discuss the need to recognize this entity.

CASE DETAILS AND MANAGEMENT

A 25-week, 700 gm baby boy had chronic lung disease and necrotizing enterocolitis. He received total parenteral nutrition, budesonide, furosemide, and caffeine. With high serum alkaline phosphatase (ALP: 1,700 IU/L) and low P (2.8 mg/dl), MBDP was diagnosed at 12 weeks, started on oral phosphate, human milk fortifier, and 1,400 IU/d of vitamin D before discharge. He was readmitted 2 weeks later with decreased lower limb mobility and respiratory distress. X-rays revealed severe osteopenia and fractures of both femurs. Serum P was 4.6 mg/dl but ALP was high (1,700 IU/L), and Ca was low (6.4 mg/dl). Parathyroid hormone (PTH: 605 pg/ml) and 25-hydroxy Vitamin D (25 OHD > 200 ng/ml) were very high. We discontinued his P and vitamin D, hypocalcemia treated with IV Ca gluconate, later oral Ca citrate, and calcitriol. Phosphate was added after normalization of Ca. Over the next many weeks, X-rays and biochemistry improved.

DISCUSSION

MBDP results from both Ca and P deficiencies, especially in VLBW infants with comorbidities. P supplementation without treating underlying calcipenia can precipitate hypocalcemia and worsen osteopenia with disastrous consequences. In severe calcipenia, active vitamin D might have a role in addition to an appropriate dose of elemental calcium.

Catch it before it breaks!: managing metabolic bone disease of prematurity

PURPOSE OF REVIEW

Metabolic bone disease of prematurity, commonly referred to as osteopenia of prematurity, remains prevalent in the neonatal intensive care unit (NICU) despite recent medical advances. It is estimated that up to 60% of extreme low birth weight and 20% of very low-birth-weight infants have metabolic bone disease of prematurity. Often silent, it typically presents with poor growth, increased ventilator dependency and fractures. Clinical sequalae, such as short stature can extend into young adulthood. There is no universal consensus by neonatal intensive care unit clinicians on the screening, diagnosis, or treatment for metabolic bone disease of prematurity. The disease is often diagnosed late by radiographs or incidentally in this highly fragile population.

RECENT FINDINGS

Suggest screening using DEXA (dual-energy X-ray absorptiometry) scans or ultrasound, in combination with serum markers like alkaline phosphatase, phosphorous levels, parathyroid hormone, and tubular reabsorption of phosphate, might identify at-risk babies earlier. The use of protocol-based screenings may aid in early diagnosis.

SUMMARY

We present a review of the risk factors, recent screening methods, diagnosis and management of this prevalent, clinically relevant diagnosis, as well as propose a protocol for the early screening and management of this silent disease.