1

Bone Health and the Preterm Infant

Bone Health and the Preterm Infant: How Physical Activity Can Help

Scharette Charlton 100392274

HLSC 4460: Selected Topics in Physical Activity and Health Professor: Meghann Lloyd, PhD April 8, 2013

Bone Health and the Preterm Infant

It is a well-known fact that fact that a majority of a newborns bone development takes place in the 3rd trimester of the gestational period. Infants who are born preterm often have lower bone density and less mineralization of their bones than infants that where carried to term. Another factor that influences the bone health of preterm infants is the fact that they often have very low birth weight (VLBW). As a matter of fact all the infants involved in a majority of these studies were of VLBW. Preterm or premature infants are at a greater risk for developing bone disease that includes bone demineralization and even reabsorption. In recent years there has been a lot of talk regarding the role of physical activity in the normal development of a child. All the experts agree that physical activity is an essential part of any childs growth and development. Recently much of the focus has been on the role physical activity can have on the health of the newborn. More specifically the focus has been how regular physical could possible improve the bone health of healthy preterm infants. This is a fairly recent area of study and there has been a lot of controversy surrounding the issue. It is however impossible to ignore all evidence that support the claim that physical activity could potentially be beneficial to the bone health of the preterm infant. An informative study by Moyer-Miluer, Burnstetter, McNaught, Gill & Chan (2002) showed that ex utero mineralization rates do not equal in utero mineralization. Bone mineralization in preterm infants is extremely low because they have greater need for bone nutrients than they did in utero (Moyer-Miluer et al., 2002). This is sometimes difficult to achieve through regular feedings. This means it is often difficult for the preterm infant to accomplish adequate bone mineralization to ensure proper bone health (Moyer-Miluer et al., 2002). While preterm infants may gain body weight normally their rates of bone mineralization do not approach normal roughly the first year of life. Preterm infants are more likely suffer from

Bone Health and the Preterm Infant

bone diseases in during childhood than infants who were carried to term (Moyer-Miluer et al., 2000). Moyer-Miluer et al (2000) stated that preterm infants are more susceptible to bone disease that full-term infants. The main goal of the study was to demonstrate the effect if any that physical inactive as on the bone health of preterm infants. Inactivity in adults and older children, especially those who are bedridden, often result in the loss of bone minerals, reabsorption of bones and other forms of bone disease. Osteoblasts are the cells that are responsible for bone generation and they become more active if a mechanical load, usually caused by physical activity, is placed on the bones. Moyer-Miluer et al (2000) argued that the prescribed care for preterm infants make it extremely difficult if not impossible for the infant to move about. This lack of physical activity is suspected of causing demineralization and reabsorption of the bones. Moyer-Miluer et al (2000) where some of the first researchers to conduct physical activity studies regarding preterm infants. This particular study consisted of thirty- six preterm infants who were considered to in good health by their doctors. All the infants who participated in the study were of similar gestational age, length, and weight and head circumference. The infants were then divided into two equal groups of sixteen infants each. Factors that could affect bone health such as gender ethnicity and adjusted weight were distributed evenly between the groups at the beginning of the study. In fact the only difference between the two groups was that one group was administered physical activity and the other group was not. The infants in the physical activity group received range of motion exercises with gentle compressions and extension/flexion against the infants passive resistance to upper and lower extremities (Moyer-Miluer et al., 2000). In order to control for touch stimulation that might account for any increase in growth; the infants in the control group were held and stroked on a daily basis. At the end of the study period researchers noted that the infants

Bone Health and the Preterm Infant

who received physical activity gained significantly more body weight than their counterparts in the control study. The researchers also note the infant in the physical activity group and longer forearms than the infants in the control. The infants in the physical activity group also had a greater increase in bone area (BA) and bone mineral content (BMC) (Moyer-Miluer et al., 2000). Based on these results the researchers concluded that physical activity is an important part of the preterm infants development. Interestingly enough physical activity does not have to be as structured or as regimented has it had been in the Moyer-Miluer study. Eliakim, Nemet, Frieland, Dolfin & Regev (2002) found that spontaneous activities can be just as effective. In this particular study the researchers measured the speed of sound (SOS) of the active and non-active tibia of three premature infants. The SOS measurement is useful because sound travels faster through bone than through soft tissue. These results were then compared with the results from ten healthy preterm infants. The three preterm infants had reduced movement on one side of their bodies due to medical complications (Elikaim et al., 2002). All infants in the study were examined by the same trained technician and the same method was also used. The technician doing the testing had no idea which infants were in the control group since all measurements were taken when the infants were in a quiet state. At the end of the study Eliakim et al (2002) noted that tibial speeds were consistently faster in the leg that was active than the one that was not. In one particular infant the SOS in the non-active leg was 3150 m/sec and 3255m/sec in the active leg (Eliakim et al., 2002). To the casual observer this might not seem like a significant difference but for the researchers it was an incredible breakthrough especially since they were able to repeat their results across the board in all the infants tested. In the control group there was no significant difference between the tibial SOS in either leg. The researchers concluded physical activity even the spontaneous

Bone Health and the Preterm Infant

kind that is usually performed by preterm infants. This result was consistent with the results obtained from the study by Moyer-Miluer et al. Other researchers have also produced significant evidence to support the claim that physical activity is indeed beneficial to the bone health of preterm infants. Based on these studies physical activity interventions seem to be a promising treatment for ensuring bone health in preterm infants. Previous studies involving assisted exercise in preterm infants usually last for approximately 4 weeks Litmanovitz, Dolfin, Arnon, Regev, Nemet and Eliakim (2007) wanted to see what would happen if the treatment period was extended to 8 weeks. One the main purposes of the study was to identify the effect on a longer exercise regimen on preterm infants. Litmanovitz et al (2007) hypothesized than by extending the duration of the exercises they could increase the proposed benefits. Similar to the studies conducted by Moyer-Miluer et al (2000) and Eliakim et al (2002) it was noted that the control group had significantly lower SOS measurements than the group who received the intervention. In addition it was noted that among the control group there was also significant decrease in bone SOS (Litmanovitz et al., 2007). One of the major discoveries of this study was that it provided tangible that extending the exercise period to 8 weeks will effectively prevent the decrease of bone SOS in preterm infant. The results of this study were consistent with the results that were obtained from other studies. The Moyer-Miluer method seems to be the expected standard of practise when evaluating the effect of physical activity on the bones of preterm infant. In fact a majority of the studies conducted are basically variations on this established method. The Vignochi, Miura, & Canani study (2008) was one such study. Vignochi et al (2008) were interested in the effect that could be achieved if the daily allotted physical activity was increased from 5 minutes a day to 15 minutes a day. Similar to the other studies mentioned all the infants in the control were interacted

Bone Health and the Preterm Infant

with regularly and consistently. The technicians who recorded the results were not aware of which the groups the infants were in and therefore could not influence the results. The results of the study were not surprising since they were consistent with the results that were obtained from other studies. The only difference between the study performed by Vignochi et al (2008) and others is the length of the physical therapy. The physical therapy performed was also similar to the ones used in previous study. At the end of the study Vignochi et al (2008) concluded that extending the physical activity from 5 minutes a day to 15 minutes a day for the same 5 times for the 4 week period will result in significantly greater weight gain, length and BMC. As was stated earlier infants who are born premature or preterm or at a significantly higher for developing bone disease than their counterparts who were born at term (Eliakim et al., (2002). The children and adults who are born prematurely have significantly shorter stature with lower bone size and mineral content than their peers (Moyer-Miluer, Ball, Burnstetter & Chan, 2008). This means that there is a growing need for more strategies that could improve bone health in premature infants beyond their initial stay in the hospital (Moyer-Miluer et al., 2008). In previous studies all of the physical therapy interventions were performed by trained therapist and in a clinical setting. Moyer-Miluer et al (2008) hypothesized that since touch simulation administered by mothers have been shown to stimulate growth and weight gain in premature infants then it stands to reason that the mothers should get similar results if they performed physical therapy on their infants. This particular differs from the others in that in not only compared the effects of physical activity against a control group who did not receive the treatment. In this particular study the researchers wanted see if the benefits of physical activity changed based on who was administering it. They wanted to know if similar results could be obtained by some who was not formally trained to perform or teach physical activity. Moyer-

Bone Health and the Preterm Infant

Miluer et al (2008) believed that there should be no significant differences between the infants who were treated by the therapist and those who were treated by their mothers. This study was significant as it is believed to be first study to investigate the effects of maternal applied physical activity. The results of the study were nothing short of astounding. The researchers were able to determine that the infants who received physical therapy from their mother received the same benefits from it as did the ones who received the interventions from a trained professional. Both groups saw a significant increase in BMC results within the first weeks of the study. In fact the BMC for the maternal group increased by 0.253g and BMC for the therapist group increased by 0.278g while the control group only increased by 0.110g proving that any level of activity is better than none (Moyer-Miluer et al., 2008). The result of the study are reliable because the technician who assessed the infants had no idea which group they fell into and therefore could not inadvertently influence the results. As with other studies conducted in this field the groups consisted of infants who were of similar gestational age, birth weight and ethnicity (MoyerMiluer et al., 2008). This means that there were no significant pre-study differences in the infants in each group. This ensured than the results would reflect the effect of the intervention and other factors such as birth weight that could affect bone health. At the end of the study Moyer et al were able to prove that it does not matter who performs the intervention the results and the benefits will be the same. Aly et al (2004) were also able to provide additional evidence to support the claims that were made by researchers such Moyer Miluer and others. Through their research they were able to produce even more evidence that supported the use of physical activity in improving the bone health of the preterm infant. The purpose of this study was to examine the effect of massage in combination with physical activity on the bone health of preterm infants. Many schools of

Bone Health and the Preterm Infant

thought believe that the stimulation from massage and touch have a positive effective on an infant promotes growth. Therefore it stands to reason that if combined with physical activity then it will positively benefit the preterm infant. In this particular study researchers used serum PICP, a biological maker that signals bone formation, to test their theory (Aly, et al., 2004). Based on previous studies, the researchers expected to see an increase in PICP in the infants that were receiving the treatment and a decrease of serum PICP in the control group (Vignochi et al 2008). The researchers were not disappointed when they noted that PICP values increased from 62.513.8ng/ml to 73.812.9ng/ml in the intervention group and decreased 82.38.5ng/ml from to 68.814.7ng/ml in the control group (Aly et al., 2004). This was slightly different from the previous studies completed by Moyer-Miluer et al (2000 , 2008) that reported that PICP remained steady in the intervention group while it declined in the control group. It is believed that the additional stimulation of the massage can account for the differences observed in this study (Aly et al., 2004). The variables that were chosen to explain the changes in bone health where an integral part of the studies and it is to understand the basis of why these variables were appropriate. As stated earlier BMC is one of the most reliable variables to for assessing bone health. BMC helps researchers to understand what is happening inside the bones and is often the go to variable in research. This is because it is relatively easy to measure and the techniques used to collect the data are non-invasive which is beneficial to the preterm infant who might at risk for infections. Another variable that has been used by several different researchers is the tibial SOS measurement. It is well known that sound travels faster through bone than it does through soft tissue. Therefore the faster the recorded speed of sound the more bone it has based through. Similar to BMC this measurement is obtained by the use of a non-invasive procedure.

Bone Health and the Preterm Infant

Various researchers have done studies involving preterm infants and the benefits of exercise on bone health and all of them have reported a positive correlation. They all agree that regardless of intensity or duration physical activity has been shown to help improve the bone health of preterm infants. While there are no predetermined guidelines for the types and duration of the exercises the results cannot be ignored. Further research is needed to determine the intensity and duration that is needed to produce optimal results. However until that is determined experts recommend that as soon as the infant is medically stable then it is important to begin some kind of physical activity. As was said earlier the type of physical activity does not matter (whether it is spontaneous or assisted) the important the thing is to get started. An early start to physical activity will lower the chances that a preterm infant will be prone to weak bones and fractures later on in his/her lifetime.

10

Bone Health and the Preterm Infant

References Aly, H., Moustafa, M. F., Hassanein, S. M., Massaro, A. N., Amer, H. A., & Patel, K. (2004). Physical activity combined with massage improves bone mineralization in premature infants: A randomized trial. Journal of Perinatology, 24(5), 305-9. doi: http://dx.doi.org/10.1038/sj.jp.7211083 Eliakim, A., Nemet, D., Friedland, O., Dolfin, T., & Regev, R. H. (2002). Spontaneous activity in premature infants affects bone strength. Journal of Perinatology, 22(8), 650-2. doi: http://dx.doi.org/10.1038/sj.jp.7210820 Litmanovitz, I., Dolfin, T., Arnon, S., Regev, R. H., Nemet, D., & Eliakim, A. (2007). Assisted exercise and bone strength in preterm infants. Calcified Tissue International, 80(1), 39-43. doi: http://dx.doi.org/10.1007/s00223-006-0149-5 Moyer-mileur, L., Ball, S. D., Brunstetter, V. L., & Chan, G. M. (2008). Maternal-administered physical activity enhances bone mineral acquisition in premature very low birth weight infants. Journal of Perinatology, 28(6), 432-7. doi: http://dx.doi.org/10.1038/jp.2008.17 Moyer-Mileur, L., Brunstetter, V., McNaught, T. P., Gill, G., & Chan, G. M. (2000). Daily physical activity program increases bone mineralization and growth in preterm very low birth weight infants. Pediatrics, 106(5), 1088-92. Retrieved from http://search.proquest.com.uproxy.library.dc-uoit.ca/docview/228390187?accountid=14694 Vignochi, C. M., Miura, E., & Canani, L. H. (2008). Effects of motor physical therapy on bone mineralization in premature infants: A randomized controlled study. Journal of Perinatology, 28(9), 624-31. doi: http://dx.doi.org/10.1038/jp.2008.60