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Re: Differentiating osteopenia of prematurity from child abuse

Dear Editor,

The review on fractures in infancy is brilliant and very informative. I would like to take this opportunity to stress the sensitive issue of fractures due to osteopenia of prematurity that many a times needs differentiating from child abuse.

Reports of osteopenia/rickets of prematurity are on the increase because of improved survival rates of low birthweight infants.2 The incidence of osteopenia among infants born before 28 weeks of gestational age are as high as 30%. 1 The contributory factors are prematurity, lack of activity, chronic lung disease, use of diuretics, prolonged parenteral nutrition and iatrogenic factors that are unavoidable in neonatal intensive care. Iatrogenic injuries are frequently the result of physiologic or anatomical response to proper and lifesaving treatment. The most serious of these are found in the premature infant, who may suffer chronic lung disease or, more seriously, brain damage.3

The diagnosis of osteopenia of prematurity remains difficult as there is no screening test which is both sensitive and specific.5 Such infants sometimes go undiagnosed of fractures from the neonatal unit and when they come back with reasons like excessive crying and the x-rays show multiple healing fractures, the differential of child abuse, unfortunately, tends to take the top position. Due to the obvious reasons and the sensitivity of the issue, clinicians have shown concerns about the mistaken diagnosis of child abuse.4

I agree with the authors that the plain film radiography is not the final arbiter of bone fragility in infancy; as with the other forms of investigation discussed in the article, it is a part of the overall approach to discriminating between a diagnosis of bone fragility and one of non-accidental injury.Dual energy X-ray absorptiometry and quantitative ultrasound has been employed by some neonatal units to determine the mineral density of the bone but it is still not universal due to the issues like ionising radiation and the difficulty to interpret data.5

As a result, the clinicians, especially the junior doctors who happen to be the first contact with the carers need to keep osteopenia of prematurity high on their list of differentials especially when a NICU graduate presents without an official diagnosis of it.

References

1. Kocsis I, Kis E, Szabó A, et al. Osteopenia of Prematurity. Orv Hetil. 2005; 146:2491-7.

2. Caksen H, Oztürk A, Kurtođlu S, et al .Reports of osteopenia/rickets of prematurity are on the increase because of improved survival rates of low birthweight infants. J Emerg Med 2002; 23:305-6.

3. Singleton EB. Intentional and unintentional abuse of infants and children. Curr Probl Diagn Radiol 1986; 15:277-330

4. Blumenthal I. Osteogenesis imperfecta, non-accidental injury, and temporary brittle bone disease. Arch Dis Child 1996; 74:91