Findings of metabolic bone disease in infants with unexplained fractures in contested child abuse investigations: a case series of 75 infants

Miller, Marvin E.; Stolfi, Adrienne; Ayoub, David

doi:10.1515/jpem-2019-0093

Cited by 27 publications

(22 citation statements)

References 74 publications

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“…Case reports have described rickets as being associated with humerus shaft fracture [19,20] and femur shaft fractures [20]. Case series have reported long bone shaft fractures associated with metabolic bone disease of infancy [21]. We found only few shaft fractures with a diagnosis of rickets or vitamin D de ciency, as previously reported for fractures of any type [22].…”

Section: Discussionsupporting

confidence: 69%

The Epidemiology of Infant Shaft Fractures of Femur or Humerus by Incidence, Birth, Accidents, and Other Causes

Iversen

Thiblin

Högberg

2020

Preprint

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Background: Knowledge of femur and humerus shaft fractures during infancy is scarce. The purpose of this population-based registry study was to analyze both birth-related femur and humerus shaft fractures and those diagnosed later in infancy, as regards incidence, perinatal characteristics, other diagnoses, and reported accidents.Methods: Children born in 1997–2014, diagnosed with a femur or humerus shaft fracture before age 1 year, were identified in the Swedish Health Registries. Rate of birth fractures were estimated by combining femur and humerus shaft fractures coded as birth-related with femur and humerus shaft fractures diagnosed during day 1-7 without registered trauma, abuse, or bone fragility disorders. Incidence was computed by comparing infants with femur or humerus shaft fractures to the total at-risk population. Results: The incidence for birth-related femur shaft fractures was 0.024‰ (n=45) and that for birth-related humerus shaft fractures was 0.101‰ (n=188). The incidence was 0.154‰ for later femur shaft fractures (n=287) and 0.073‰ for later humerus shaft fractures (n=142). Birth-related femur shaft fracture was associated with preterm, multiple birth, breech, cesarean, and small-for-gestational age, while humerus shaft fracture was associated with preterm, multiple birth, birth weight > 4,000 g, and shoulder dystocia. A bone fragility diagnosis was recorded in 5% of those with birth-related or later femur shaft fractures. Among infants with birth-related humerus shaft fractures, 1% had a bone fragility diagnosis; the figure for later fractures was 6%. Maltreatment diagnosis was associated with both fracture types, especially among those aged < 6 months, where approximately 20% and 14% of cases, respectively, were associated with abuse. Fall accidents were reported in 73% and 56% among those with later femur and humerus shaft fractures, respectively. Conclusion: This study provides data on epidemiology, birth, parental characteristics, and reported accidents in relation to femur and humerus shaft fractures during infancy. Few children had a bone fragility diagnosis. Fall accidents were the main contributor to femur or humerus shaft fracture during infancy; however, the proportion of fractures attributed to maltreatment was high in children under 6 months.

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Section: Discussionsupporting

confidence: 69%

The Epidemiology of Infant Shaft Fractures of Femur or Humerus by Incidence, Birth, Accidents, and Other Causes

Iversen

Thiblin

Högberg

2020

Preprint

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“…Expedient exploration of this relationship is crucial due to considerable debate in the literature as to whether fractures due to osteomalacia/rickets can be differentiated from fractures due to nonaccidental trauma by X-ray or laboratory markers [54][55][56][57]. Currently, published literature points to the consideration of bone biopsy as a method to detect hypomineralization disease versus child abuse.…”

Section: Vitamin D In Pediatric Bone Healthmentioning

confidence: 99%

Vitamin D in Toddlers, Preschool Children, and Adolescents

Taylor

2020

Ann Nutr Metab

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Background: Vitamin D supplementation is known to both prevent and treat rickets, a disease of hypomineralized bone. Childhood is a period of great bone development and, therefore, attention to the vitamin D needed to optimize bone health in childhood is imperative. Summary: Observational studies have pointed to a vitamin D status, as indicated by a 25-hydroxyvitamin D concentration, of 50 nmol/L to ensure avoidance of rickets and of 75 nmol/L to optimize health. However, the benefits of achieving these levels of vitamin D status are less evident when pediatric randomized, controlled trials are performed. In fact, no specific pediatric vitamin D supplementation has been established by the existing evidence. Yet, study of vitamin D physiology continues to uncover further potential benefits to vitamin D sufficiency. This disconnection between vitamin D function and trials of supplementation has led to new paths of investigation, including establishment of the best method to measure vitamin D status, examination of genetic variation in vitamin D metabolism, and consideration that vitamin D status is a marker of another variable, such as physical activity, and its association with bone health. Nevertheless, vitamin D supplementation in the range of 10–50 μg/day appears to be safe for children and remains a promising intervention that may yet be supported by clinical trials as a method to optimize pediatric health. Key Message: Pediatric vitamin D status is associated with avoidance of rickets. Randomized, controlled trials of vitamin D supplementation for pediatric bone health are limited and equivocal in their results. Beyond bone, decreased risk for autoimmune, infectious, and allergic diseases has been associated with higher vitamin D status. The specific vitamin D supplementation to optimize toddler, child, and adolescent outcomes is unknown, but doses 10–50 μg/day are safe and may be beneficial.

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“…The injury mechanism depends on the child's age, with younger children most likely to be injured by falls and older children and adolescents by traffic-related accidents [4][5][6]. In children < 1 year of age and who have not yet learned to walk, child (physical) abuse or metabolic bone disease is considered a possible cause of the femur fracture [4,5,7,8].…”

Section: Introductionmentioning

confidence: 99%

Epidemiology of pediatric femur fractures in children: the Swedish Fracture Register

Engström

Wolf

Hailer

2020

BMC Musculoskelet Disord

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Background Although femur fractures in children are rare, they are the most common fractures in need of hospitalization. We sought to describe the epidemiology and treatment of pediatric femur fractures recorded in the Swedish Fracture Register (SFR). We also studied the relationship between femur fractures, age, sex, fracture pattern, injury mechanism, seasonal variation and treatment. Methods This nationwide observational register study was based on the pediatric part of the SFR. We included all patients < 16 years of age who were registered in the SFR from 2015 to 2018. Results Of the 709 femur fractures, 454 (64%) occurred in boys. Sixty-two of these fractures were proximal (9%), 453 shaft (64%) and 194 distal (27%). A bimodal age distribution peak was observed in boys aged 2–3 and 16–19 years. In contrast, the age distribution among girls was evenly distributed. Younger children were mainly injured by a fall, whereas older children sustained their fracture because of traffic accidents. Non-surgical treatment prevailed among younger children; however, prevalence of surgical treatment increased with age. Conclusions We found a lower ratio between boys and girls (1.8:1) compared to earlier studies. The bimodal age distribution was seen only in boys. Falls were the most common injury in younger children, whereas traffic-related accidents were the most common in adolescents. With age, there was a corresponding increase in surgical treatment.

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Findings of metabolic bone disease in infants with unexplained fractures in contested child abuse investigations: a case series of 75 infants

Cited by 27 publications

References 74 publications

The Epidemiology of Infant Shaft Fractures of Femur or Humerus by Incidence, Birth, Accidents, and Other Causes

The Epidemiology of Infant Shaft Fractures of Femur or Humerus by Incidence, Birth, Accidents, and Other Causes

Vitamin D in Toddlers, Preschool Children, and Adolescents

Epidemiology of pediatric femur fractures in children: the Swedish Fracture Register

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