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Rickets and Osteopenia of Prematurity

By Helen Harrison

Approximately 50% of very low birthweight infants develop "osteopenia of prematurity" (decreased bone density) with rickets (demineralized bones with a predominance of uncalcified bone matrix) which in turn may lead to traumatic or non-traumatic(i.e. spontaneous) fracture. (1)

Osteopenia may become quite serious and contribute to other medical problems. One of the most startling and haunting passages from the book, "The Long Dying of Baby Andrew" involved the note written in Baby Andrew's chart by the radiologist saying the only time he had seen more fractures was in an airforce crash victim!  This was in a 26 week preemie who never left the NICU. One of the reasons the neonatologists cited for Andrew's inability to be successfully weaned from the ventilator was that with all his fractured ribs "it hurts like hell each time he takes a breath." (2)

Ricketsand/or osteopenia (which are not exactly the same, but usually go together in preemies) are characterized by low levels of calcium and phosphate and high levels of serum alkaline phosphotase.  Low levels of Vitamin D or inability of preemies to properly metabolize Vitamin D contribute to bone abnormalities and fractures.  Lack of trace elements, such as copper sulfate may play a role as well. (3) BPD babies are at especially high risk because of their general nutritional problems and because of diuretics such as lasix which cause abnormal excretion of calcium and other minerals. (4) Another high-risk group is made up of preemies receiivng unsupplemented breast milk.  Despite the many documented benefits of breast milk for preemies it just doesn't have enough phosphate and calcium to support preemies' rapid bone growth.  This is an important reason to use breast milk supplements. (3)  Babies receiving long-term TPN (total parenteral nutrition) are also a group at risk. (5) Treatment with dexamethasone (steroids) is another major risk factor for poor bone growth and development.

Supplementation of minerals and vitamins should be done carefully and under a physician's guidance, because a balance of nutrients is important and because Vit. D overdoses can be toxic.

One intervention that seems to help (other than nutritional supplements) is exercise which which has been found to stimulate bone growth and density. (1)

I'm not sure there are clear cut answers to this, but at least one study indicates that preemies who "catch up" in weight by age one have better bone status in later life.  This would seem to indicate that attention to this potential problem should extend through the first year at least. Here is the conclusion of that study: 

"The data suggest that catch up weight growth by one year corrected age in infants born below 1500 grams establishes growth trajectory and also supports development of greater bone mass in adolescence. In contrast, since attainment of adult weight and height is positively associated with with development of peak bone mass, it is speculated that infants who do not achieve catch-up weight growth by one year will not achieve growth trajectories and will consequently have lower peak bone mass in adulthood." (6)

I have also found at least one of the "later life" studies which showed that preemies (compared to fullterm children) continue to have poor bone mineralization throughout childhood. (7)


1. Moyer-Mileur. Physical activity and diet: key components for improved bone mass in premature, very low birth weight infants. Pediatric Research 1999;45:287A #1692.
2. Stinson and Stinson. The Long Dying of Baby Andrew. Atlantic, Little Brown, 1983.
3. Anast. Disorders of calcium and phosphorus metabolism. in Tausch, Ballard and Avery Shaffer and Avery's Diseases of the Newborn 6th Edition 1991. pp 927-937.
4. Wahlig and Georgieff. The effects of illness on nutritional metabolism and nutritional management. Clinics in Perinatology 1995;22:77-96.
5. Macpherson et al. Prevention and reduction of iatrogenic disorders in the newborn. in Guthrie (ed) Neonatal Intensive Care Churchill-Livingstone, 1988, pp. 271-312.
6. Weiler et al. "Weight at one year corrected age of infants <1500 grams at birth is positively associated with weight, height and bone mineral content of adolescents." Pediatric Research1998;43:234A #1367.
7. Armstrong et al. Seven year follow-up of preterm infants' bone mineralization. Pediatric Research 1997;41:190A #1127.

Helen Harrison is the well known author of The Premature Baby Book, often referred to as the "Bible of Prematurity" by older preemie parents. These observations are excerted with permission from posts to the prematurity parents support internet mailing lists on prematurity: Preemie-child and Preemie-L.

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