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Bone. 2017 Apr;97:287-292. doi: 10.1016/j.bone.2017.02.003. Epub 2017 Feb 4.

Unexpected widespread hypophosphatemia and bone disease associated with elemental formula use in infants and children.

Author information

1
Yale University School of Medicine, Department of Pediatrics, New Haven, CT, United States.
2
Boston Children's Hospital, Boston, MA, United States.
3
Columbia University Medical Center, New York, NY, United States.
4
Children's Hospital of Eastern Ontario, Ottawa, ON, Canada.
5
Cincinnati Children's Hospital, Cincinnati, OH, United States.
6
University of Rochester, Rochester, NY, United States.
7
Riley Hospital for Children, Indiana University, Indianapolis, IN, United States.
8
Centre Hospitalier de l'Université Laval, Quebec City, QC, Canada.
9
Children's Hospital of Western Ontario, London, ON, Canada.
10
Our Lady's Children's Hospital, Crumlin, Ireland.
11
Children's Hospital Colorado, Denver, CO, United States.
12
University of Vermont Medical Center, Burlington, VT, United States.
13
Alpert Medical School of Brown University, Providence, RI, United States; Hasbro Children's Hospital, Providence, RI, United States.
14
Children's Hospital of Philadelphia, Philadelphia, PA, United States.
15
Mayo Clinic, Rochester, MN, United States.
16
Walter Reed National Military Medical Center, Bethesda, MD, United States.
17
British Columbia Children's Hospital, Vancouver, BC, Canada.
18
Yale University School of Medicine, Department of Pediatrics, New Haven, CT, United States. Electronic address: thomas.carpenter@yale.edu.

Abstract

OBJECTIVE:

Hypophosphatemia occurs with inadequate dietary intake, malabsorption, increased renal excretion, or shifts between intracellular and extracellular compartments. We noticed the common finding of amino-acid based elemental formula [EF] use in an unexpected number of cases of idiopathic hypophosphatemia occurring in infants and children evaluated for skeletal disease. We aimed to fully characterize the clinical profiles in these cases.

METHODS:

A retrospective chart review of children with unexplained hypophosphatemia was performed as cases accumulated from various centres in North America and Ireland. Data were analyzed to explore any relationships between feeding and biochemical or clinical features, effects of treatment, and to identify a potential mechanism.

RESULTS:

Fifty-one children were identified at 17 institutions with EF-associated hypophosphatemia. Most children had complex illnesses and had been solely fed Neocate® formula products for variable periods of time prior to presentation. Feeding methods varied. Hypophosphatemia was detected during evaluation of fractures or rickets. Increased alkaline phosphatase activity and appropriate renal conservation of phosphate were documented in nearly all cases. Skeletal radiographs demonstrated fractures, undermineralization, or rickets in 94% of the cases. Although the skeletal disease had often been attributed to underlying disease, most all improved with addition of supplemental phosphate or change to a different formula product.

CONCLUSION:

The observed biochemical profiles indicated a deficient dietary supply or severe malabsorption of phosphate, despite adequate formula composition. When transition to an alternate formula was possible, biochemical status improved shortly after introduction to the alternate formula, with eventual improvement of skeletal abnormalities. These observations strongly implicate that bioavailability of formula phosphorus may be impaired in certain clinical settings. The widespread nature of the findings lead us to strongly recommend careful monitoring of mineral metabolism in children fed EF. Transition to alternative formula use or implementation of phosphate supplementation should be performed cautiously with as severe hypocalcemia may develop.

PMID:
28167344
PMCID:
PMC5884631
DOI:
10.1016/j.bone.2017.02.003
[Indexed for MEDLINE]
Free PMC Article

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