Title:A Multidisciplinary and a Comprehensive Approach to Reducing Fragility
Fractures in Preterm Infants
Volume: 20
Issue: 4
Author(s): Saif Al Saif, Mohammad Maghoula, Amir Babiker, Mashael Abanmi, Fiona Nichol, Modhi Al Enazi, Elenor Guevarra, Faisal Sehlie, Hesham Al Shaalan and Zulf Mughal*
Affiliation:
- Department of Paediatric Endocrinology, Royal Manchester Children’s Hospital, Manchester, UK
- Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK
Keywords:
Calcium, fragility fractures, metabolic bone disease of prematurity, parathyroid hormone, parenteral nutrition, preterm infant, phosphate.
Abstract: With advances in neonatal care, bone fractures prior to discharge from the hospital in
preterm infants receiving contemporary neonatal care, are rare. Nevertheless, such fractures do occur
in very low birth weight and extremely low birth weight infants who go on to develop metabolic
bone disease of prematurity (MBDP), with or without secondary hyperparathyroidism. MBDP is a
multifactorial disorder arising from the disruption of bone mass accrual due to premature birth,
postnatal immobilisation, and loss of placental oestrogen resulting in bone loss, inadequate provision
of bone minerals from enteral and parenteral nutrition, and medications that leach out bone
minerals from the skeleton. All of these factors lead to skeletal demineralisation and a decrease in
bone strength and an increased risk of fractures of the long bones and ribs. Secondary hyperparathyroidism
resulting from phosphate supplements, or enteral/parenteral feeds with a calcium-tophosphate
ratio of < 1.3:1.0 leads to subperiosteal bone resorption, cortical thinning, and further
skeletal weakening. Such fractures may occur from routine handling and procedures such as cannulation.
Most fractures are asymptomatic and often come to light incidentally on radiographs performed
for other indications. In 2015, we instituted a comprehensive and multidisciplinary Neonatal
Bone Health Programme (NBHP), the purpose of which was to reduce fragility fractures in highrisk
neonates, by optimising enteral and parenteral nutrition, including maintaining calcium-tophosphate
ratio ≥1.3:1, milligram to milligram, biochemical monitoring of MBDP, safe-handling of
at-risk neonates, without compromising passive physiotherapy and skin-to-skin contact with parents.
The at-risk infants in the programme had radiographs of the torso and limbs at 4 weeks and after
8 weeks from enrolment into the program or before discharge. Following the introduction of the
NBHP, the bone fracture incidence reduced from 12.5% to zero over an 18-month period.
