title: Fractures Related to Metabolic Bone Disease in Children with Congenital Heart Disease.
abstract: OBJECTIVE
  Critically ill children with congenital heart disease (CHD) are at risk for metabolic bone disease (MBD) and bone fractures. Our objective was to characterize a cohort of CHD patients with fractures and describe a Fragile Bone Protocol (FBP) developed to reduce fractures.
  
  
  METHODS
  Patients who developed fractures in the Cardiac Intensive Care Unit (CICU) of Boston Children's Hospital from 3/2008 to 6/2014 were identified via quality improvement and radiology databases. The FBP (initiated July 2011) systematically identifies patients at risk for MBD and prescribes special handling precautions.
  
  
  RESULTS
  Twenty-three fractures were identified in 15 children. Median age at fracture identification was 6.2 months, with a median duration of hospitalization before fracture diagnosis of 2.7 months. Six patients (40%) had single ventricle CHD. Hyperparathyroidism and low 25-OH vitamin D levels were present in 77% and 40% of those tested, respectively. Compared with patients not diagnosed with fractures, fracture patients had increased exposure to possible risk factors for MBD and had elevated parathyroid and decreased calcitriol levels.Six patients (40%) did not survive to hospital discharge, compared with an overall CICU mortality rate of 2.6% (P < .01). The fracture case rate before implementation of the FBP was 2.6 cases/1000 admissions and was 0.7/1000 after implementation of the FBP (P = .04).
  
  
  CONCLUSIONS
  Critically ill CHD patients are at risk for fractures. They represent a complex group who frequently has hyperparathyroidism and decreased calcitriol levels, and each may predispose to fractures. FBPs consisting of identification and careful patient handling should be considered in at-risk patients.
authors: Department of Cardiology, Boston Children's Hospital, Boston, Mass, USA.
authors: Henry H
authors: HH
authors: Cheng
authors: Department of Pediatric Intensive Care, Hospital das Clinicas of Ribeirao Preto Medical School, University of São Paulo, São Paulo, Brazil.
authors: Fabio
authors: F
authors: Carmona
authors: Department of Cardiology, Boston Children's Hospital, Boston, Mass, USA.
authors: Erica
authors: E
authors: McDavitt
authors: Department of Cardiology, Boston Children's Hospital, Boston, Mass, USA.
authors: Daniel
authors: D
authors: Wigmore
authors: Department of Radiology, Boston Children's Hospital, Boston, Mass, USA.|Department of Radiology, Harvard Medical School, Boston, Mass, USA.
authors: Jeannette M
authors: JM
authors: Perez-Rossello
authors: Department of Medicine, Boston Children's Hospital, Boston, Mass, USA.|Department of Pediatrics, Harvard Medical School, Boston, Mass, USA.|Department of Adolescent Medicine and Endocrinology, Hasbro Children's Hospital and Albert Medical School, Brown University, Providence, RI, USA.
authors: Catherine M
authors: CM
authors: Gordon
authors: Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass, USA.|Department of Surgery, Harvard Medical School, Boston, Mass, USA.
authors: Frank A
authors: FA
authors: Pigula
authors: Department of Critical Care Medicine, Hospital for Sick Children, Toronto, ON, Canada.
authors: Peter C
authors: PC
authors: Laussen
authors: Department of Cardiology, Boston Children's Hospital, Boston, Mass, USA.|Department of Pediatrics, Harvard Medical School, Boston, Mass, USA.
authors: Satish K
authors: SK
authors: Rajagopal
mesh_terms: D000367:Age Factors; D015415:Biomarkers / Q000097:blood; D001851:Bone Diseases, Metabolic / Q000097:blood / Q000175:diagnosis / Q000209:etiology* / Q000628:therapy; D001900:Boston; D002117:Calcitriol / Q000097:blood; D002985:Clinical Protocols; D016638:Critical Illness; D005260:Female; D050723:Fractures, Bone / Q000000981:diagnostic imaging / Q000209:etiology* / Q000517:prevention & control; D006330:Heart Defects, Congenital / Q000150:complications* / Q000175:diagnosis / Q000628:therapy; D017052:Hospital Mortality; D006776:Hospitals, Pediatric; D006801:Humans; D006961:Hyperparathyroidism / Q000097:blood / Q000209:etiology / Q000628:therapy; D007223:Infant; D007226:Infant Mortality; D007902:Length of Stay; D008297:Male; D010281:Parathyroid Hormone / Q000097:blood; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors
chemical_list: D015415:Biomarkers; C470125:PTH protein, human; D010281:Parathyroid Hormone; D002117:Calcitriol
keywords: Bone Diseases; Congenital; Critical Illness; Fractures; Heart Defects; Metabolic; Pediatrics; Risk Factors; Spontaneous