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metabolic bone disease of prematurity or neonatal osteopenia


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Hi everyone,

I would like to get some enlightment on pratical aspect of the metabolic bone disease of prematurity or neonatal osteopenia. I have tried to find some reviews but I must confess that, in clinical situation, i am sligthly lost.

- Do you perform systematic screening? To whom? How?

- How do you diagnose this condition? Based on x-ray, ALP, Ca / P serum, urine Ca / P?

- How do you treat? For how long? How do you monitor treatment?

and... do you have a nice guidelines for dummies? 😉 

Many thanks in advance.



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My reply is loosly based on AAPs policy statement.

1. All babies less than 1500 gms are screened after 4 weeks with Ca ALP PO4. If the screens are normal, the tests are repeated till ALP values stabilise. Screening Xray am not sure.

2. A combination of ALP more than 800-1000 IU/L & PO4 less than 4 mg/dl is highly suggestive of OOP. X Ray evidence can be collaborative

3. Treatment is by increasing the calcium & PO4 intake, either enterally or if not feasible parenterally. Normal vitamin D requirements should be supplemented. If 25(OH)D is low, Vitamin D therapeutic doses can be given.

Please do go through AAP Policy statement. The chapter in Fanaroff & Martin is almost same as that of AAPs recommendation. 


Viraraghavan V Ramaswamy

MD, DM (Neonatology), DNB (Neonatology)


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@Dr Vira - is the AAP policy available online?

@AntoineBachy - I summarize our national guidelines in Sweden,  try Google translate :) http://neo.barnlakarforeningen.se/wp-content/uploads/sites/14/2017/12/Osteopeni-20-dec-2017-reviderad-slutversion.pdf

  1. Yes, we do screening in infants based on BW, and screen infants <1500g, and check blood levels of phospate and ALP at 4-6 weeks.
  2. given low phospate (<1,6 mmol/L) and/or high ALP (>15 µkat/L), we do  x-ray of the wrist and if there is rachitis - we set the osteopenia diagnoses
  3. All infants <1500 g are given supplemental Ca/P, and those with rachitis continue until the x-ray of the wrist has normalized.

We had this topic on the first 99nicu Meetup in Stockholm, find the (low-tech) video below


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@Dr Vira - it is indeed allowed to share links but sharing PDF's of publications not open-access (i.e. downloaded from hospital libraries for example) cannot be done.

If we find out, we delete such attachments, but the responsibility is the posting member's.

We state early in our Terms (agreed upon when registering) that copyrighted material shall not be posted: https://99nicu.org/terms/ 


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  • 3 weeks later...
  • 2 weeks later...

Hi Antoine,

Screening - In all VLBW infants <1500 g - Check - Serum P,  Alkaline phosphatase &  PTH. Start at four weeks of age with subsequent biweekly testing. In infants <2000 g screening only if risk factors

Diagnosis - Biochemical features – Low P <1.3mmo/l,  ALP>1000,  Normal Ca (rare for low Calcium),  Elevated PTH.

If Alk Phos⬆︎ & Phosphate⬇︎ - Measure 25OHD & PTH 

PTH⬆︎ - -Likely Ca+ and/or Vit.D def.  -   Start Ca suppl. Optimise 25OHD. Stop P supplements if prescribed. Ensure enteral (milk + supplements) Ca:P ratio 1.6:1 to 1.8:1
Optimise Ca in PN if prescribed (Ca:P ratio ~1.7 :1)

PTH - Normal - -Likely Phosphate def. - Consider P supplements.Ensure enteral (milk + supplements)Ca:P ratio >1.6:1 – add Ca supplements if needed to ensure balance.

Repeat bone profile &PTH in 2 weeks

If 25OHD <50 nmol/L (vitamin D deficiency – 25OHD <30 nmol/L; vitamin D insufficiency – 25OHD 30-50 nmol/L) • Ensure on regular multivitamins (containing 400 IU/day cholecalciferol)







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