Management of neonatal bone health
- Steven A Abrams, MD
Steven A Abrams, MD
- Section Editor — Neonatology
- Professor, Department of Pediatrics
- Dell Medical School at the University of Texas at Austin
- Section Editors
- Joseph A Garcia-Prats, MD
Joseph A Garcia-Prats, MD
- Section Editor — Neonatology
- Professor of Pediatrics
- Baylor College of Medicine
- Kathleen J Motil, MD, PhD
Kathleen J Motil, MD, PhD
- Section Editor — Pediatric Nutrition
- Professor of Pediatric Nutrition
- Baylor College of Medicine
Bone health is a critically important concern in the neonate, especially for premature infants who are at risk for rickets. Because of their rapid growth, all neonates when compared with older individuals have higher relative requirements of calcium (Ca) and phosphorus (P), which are critical components for bone structural integrity and growth. Preterm infants have even greater dietary requirements, as they need to compensate for the loss of accretion of these nutrients during the third trimester of pregnancy.
The management of bone health in neonates, including preterm infants, will be reviewed here.
Neonatal bone health is critical during this active period of growth. As a result, it is imperative that infants receive the necessary intake of the key nutrients calcium (Ca) and phosphorus (P) to ensure adequate mineralization for bone structural integrity and growth. The daily requirement of these nutrients is affected by the gestational age of the infant, and factors that affect intestinal absorption and urinary excretion.
Gestational age and placental transfer — During pregnancy, calcium and phosphorus are actively transferred from the mother to the fetus, reaching a peak accretion rate at 32 to 36 weeks gestation for calcium of 100 to 130 mg/kg of fetal weight per day, and for phosphorus, 60 to 70 mg/kg of fetal weight per day [1-4]. The third trimester is the period of most active growth and the increased accretion rate is in response to the higher fetal needs for the developing skeleton. As a result, requirements of Ca and P increase with decreasing gestational age to compensate for the loss of accretion of these minerals.
In particular, extremely low birth weight (ELBW) infants (birth weights below 1000 g) or those born before 27 weeks gestation are at high risk for rickets [3,5,6]. Unfortified human milk, parenteral nutrition, and formulas designed for term infants do not contain enough Ca and P to fully meet the needs for bone mineralization in preterm infants. As a result, the use of these diets without further supplementation would limit bone growth, resulting in rickets, and potentially increase the risk of bone fractures. (See 'Rickets in premature infants' below.)
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- Gestational age and placental transfer
- Intestinal absorption
- Renal excretion and absorption
- MANAGEMENT OF BONE HEALTH IN PRETERM INFANTS
- In-hospital management
- - Enteral nutrition
- Calcium and phosphorus
- Vitamin D
- Choice of dietary source: fortified human milk and preterm formula
- - Parenteral nutrition
- - Physical stimulation
- - Assessment and management
- Postdischarge management
- - Breastfed infants
- - Formula-fed infants
- RICKETS IN PREMATURE INFANTS
- Risk factors
- Clinical features
- MANAGEMENT OF BONE HEALTH IN TERM INFANTS
- Human milk
- - Vitamin D supplementation
- - Vitamin D
- SUMMARY AND RECOMMENDATIONS