title: Physical activity programs for promoting bone mineralization and growth in preterm infants.
abstract: BACKGROUND
  Lack of physical stimulation may contribute to metabolic bone disease of preterm infants, resulting in poor bone mineralization and growth. Physical activity programs combined with adequate nutrition might help to promote bone mineralization and growth.
  
  
  OBJECTIVE
  The primary objective was to assess whether physical activity programs in preterm infants improve bone mineralization and growth and reduce the risk of fracture.The secondary objectives included other potential benefits in terms of length of hospital stay, skeletal deformities and neurodevelopmental outcomes, and adverse events.Subgroup analysis:• Given that the smallest infants are most vulnerable for developing osteopenia (Bishop 1999), a subgroup analysis was planned for infants with birth weight < 1000 g.• Calcium and phosphorus intake may affect an infant's ability to increase bone mineral content (Kuschel 2004). Therefore, an additional subgroup analysis was planned for infants receiving different amounts of calcium and phosphorus, along with full enteral feeds as follows. ∘ Below 100 mg/60 mg calcium/phosphorus or equal to/above 100 mg/60 mg calcium/phosphorus per 100 mL milk. ∘ Supplementation of calcium without phosphorus. ∘ Supplementation of phosphorus without calcium.
  
  
  METHODS
  The standard search strategy of the Cochrane Neonatal Review Group (CNRG) was used. The search included the Cochrane Central Register of Controlled Trials (CENTRAL) (2012, Issue 9), MEDLINE, EMBASE, CINAHL (1966 to March 2013), and cross-references, as well as handsearching of abstracts of the Society for Pediatric Research and the International Journal of Sports Medicine.
  
  
  METHODS
  Randomized and quasi-randomized controlled trials comparing physical activity programs (extension and flexion, range-of-motion exercises) versus no organized physical activity programs in preterm infants.
  
  
  METHODS
  Data collection, study selection, and data analysis were performed according to the methods of the CNRG.
  
  
  RESULTS
  Eleven trials enrolling 324 preterm infants (gestational age 26 to 34 weeks) were included in this review. All were small (N = 16 to 50) single-center studies that evaluated daily physical activity for three and one-half to eight weeks during initial hospitalization. Methodological quality and reporting of included trials were variable.Four trials demonstrated moderate short-term benefits of physical activity for bone mineralization at completion of the physical activity program. The only trial assessing long-term effects on bone mineralization showed no effect of physical activity administered during initial hospitalization on bone mineralization at 12 months corrected age. Meta-analysis from four trials demonstrated a positive effect of physical activity on daily weight gain (weighted mean difference (WMD) 2.21 g/kg/d, 95% confidence interval (CI) 1.23 to 3.19). Data from four trials showed a positive effect on linear growth (WMD 0.12 cm/wk, 95% CI 0.01 to 0.24) but not on head growth (WMD -0.03 cm/wk, 95% CI -0.14 to 0.08) during the study period. Only one trial reported on fractures (this outcome did not occur in intervention and control groups) and complications of preterm birth (no significant differences between intervention and control groups). None of the trials assessed other outcomes relevant to this review.
  
  
  CONCLUSIONS
  Some evidence suggests that physical activity programs might promote short-term weight gain and bone mineralization in preterm infants. Data are inadequate to allow assessment of harm or long-term effects. Current evidence does not support the routine use of physical activity programs in preterm infants. Further trials incorporating infants with a high baseline risk of osteopenia are required. These trials should address adverse events, long-term outcomes, and the effects of nutritional intake (calories, protein, calcium, phosphorus).
authors.affiliation: Department of Neonatology, University of Basel Children's Hospital (UKBB), Spitalstrasse 21, Basel, Switzerland, 4031.
authors.forename: Sven M
authors.initials: SM
authors.lastname: Schulzke
authors.forename: Siree
authors.initials: S
authors.lastname: Kaempfen
authors.forename: Daniel
authors.initials: D
authors.lastname: Trachsel
authors.forename: Sanjay K
authors.initials: SK
authors.lastname: Patole
mesh_terms: D015519:Bone Density / Q000502:physiology; D001851:Bone Diseases, Metabolic / Q000517:prevention & control; D002113:Calcification, Physiologic / Q000502:physiology*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007234:Infant, Premature / Q000254:growth & development / Q000502:physiology*; D009043:Motor Activity / Q000502:physiology*; D026201:Musculoskeletal Manipulations / Q000379:methods*; D016032:Randomized Controlled Trials as Topic; D015430:Weight Gain / Q000502:physiology
references.citation: J Pediatr. 1980 Mar;96(3 Pt 2):528-34
references.pmid: 7359255
references.citation: J Bone Miner Res. 1988 Apr;3(2):193-7
references.pmid: 3213615
references.citation: J Pediatr. 1995 Oct;127(4):620-5
references.pmid: 7562289
references.citation: J Pediatr Orthop. 2000 Jan-Feb;20(1):71-4
references.pmid: 10641693
references.citation: J Perinatol. 2008 Jun;28(6):432-7
references.pmid: 18337741
references.citation: Calcif Tissue Int. 2007 Jan;80(1):39-43
references.pmid: 17164971
references.citation: J Bone Miner Res. 1991 Nov;6(11):1227-33
references.pmid: 1805545
references.citation: JAMA. 1996 Aug 28;276(8):637-9
references.pmid: 8773637
references.citation: Lancet. 1996 Nov 16;348(9038):1343-7
references.pmid: 8918277
references.citation: J Paediatr Child Health. 2010 Nov;46(11):653-9
references.pmid: 20796178
references.citation: Arch Dis Child Fetal Neonatal Ed. 2004 Jul;89(4):F360-3
references.pmid: 15210676
references.citation: Int Orthop. 1981;5(4):241-5
references.pmid: 7341508
references.citation: Pediatrics. 2000 Nov;106(5):1088-92
references.pmid: 11061779
references.citation: Cochrane Database Syst Rev. 2004;(2):CD000390
references.pmid: 15106151
references.citation: Int J Epidemiol. 1996 Oct;25(5):1053-9
references.pmid: 8921494
references.citation: J Perinatol. 2004 May;24(5):305-9
references.pmid: 15071483
references.citation: Am J Perinatol. 2012 Sep;29(8):573-8
references.pmid: 22773291
references.citation: J Perinatol. 2002 Oct-Nov;22(7):550-4
references.pmid: 12368971
references.citation: Bone. 2004 Apr;34(4):755-64
references.pmid: 15050908
references.citation: Int J Sports Med. 2002 Feb;23(2):82-5
references.pmid: 11842353
references.citation: Am J Clin Nutr. 2004 Dec;80(6):1595-603
references.pmid: 15585774
references.citation: Cochrane Database Syst Rev. 2007 Apr 18;(2):CD005387
references.pmid: 17443587
references.citation: J Perinatol. 2009 May;29(5):352-7
references.pmid: 19148112
references.citation: Acta Paediatr. 1992 Dec;81(12):953-8
references.pmid: 1290856
references.citation: Cochrane Database Syst Rev. 2004;(1):CD000343
references.pmid: 14973953
references.citation: J Perinatol. 2008 Sep;28(9):624-31
references.pmid: 18633420
references.citation: Arch Dis Child. 1989 Jul;64(7 Spec No):902-9
references.pmid: 2774631
references.citation: Neurosurgery. 2004 Aug;55(2):380-3; discussion 383-4
references.pmid: 15271244
references.citation: Cochrane Database Syst Rev. 2002;(3):CD000333
references.pmid: 12137611
references.citation: Pediatrics. 2003 Jul;112(1 Pt 1):15-9
references.pmid: 12837861
references.citation: J Bone Miner Res. 2001 Jan;16(1):175-81
references.pmid: 11149482
references.citation: Pediatrics. 2001 Sep;108(3):703-11
references.pmid: 11533340
references.citation: Bone. 2012 Oct;51(4):661-6
references.pmid: 22846674
references.citation: Neonatal Netw. 1992 Mar;11(2):23-7
references.pmid: 1549073
references.citation: Ann Hum Biol. 2011 Sep;38(5):635-9
references.pmid: 21745153