Hindawi Publishing Corporation

Journal of Osteoporosis
Volume 2012, Article ID 672403, 8 pages
doi:10.1155/2012/672403

Research Article
Normative Data for Bone Mass in Healthy Term Infants from
Birth to 1 Year of Age

Sina Gallo,1 Catherine A. Vanstone,1 and Hope A. Weiler1, 2

1 School of Dietetics and Human Nutrition, McGill University, 21111 Lakeshore Road, Ste-Anne-de-Bellevue, QC, Canada H9X 3V9
2 Human Nutritional Sciences, University of Manitoba, Winnipeg, MB, Canada R3T 2N2

Correspondence should be addressed to Hope A. Weiler, hope.weiler@mcgill.ca

Received 13 June 2012; Revised 25 August 2012; Accepted 26 August 2012

Academic Editor: E. M. Lewiecki

Copyright © 2012 Sina Gallo et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

For over 2 decades, dual-energy X-ray absorptiometry (DXA) has been the gold standard for estimating bone mineral density
(BMD) and facture risk in adults. More recently DXA has been used to evaluate BMD in pediatrics. However, BMD is usually
assessed against reference data for which none currently exists in infancy. A prospective study was conducted to assess bone mass
of term infants (37 to 42 weeks of gestation), weight appropriate for gestational age, and born to healthy mothers. The group
consisted of 33 boys and 26 girls recruited from the Winnipeg Health Sciences Center (Manitoba, Canada). Whole body (WB)
as well as regional sites of the lumbar spine (LS 1–4) and femur was measured using DXA (QDR 4500A, Hologic Inc.) providing
bone mineral content (BMC) for all sites and BMD for spine. During the year, WB BMC increased by 200% (76.0 ± 14.2 versus
227.0 ± 29.7 g), spine BMC by 130% (2.35 ± 0.42 versus 5.37 ± 1.02 g), and femur BMC by 190% (2.94 ± 0.54 versus 8.50 ± 1.84 g).
Spine BMD increased by 14% (0.266 ± 0.044 versus 0.304 ± 0.044 g/cm2 ) during the year. This data, representing the accretion of
bone mass during the first year of life, is based on a representative sample of infants and will aid in the interpretation of diagnostic
DXA scans by researchers and health professionals.

1. Introduction as the preferred scan sites in pediatrics. Regional scans of the

spine may also be easier to obtain in infants and children
Bone diseases are being increasingly recognized as a problem because these are less sensitive to movement artefact because
which begins in early life. Dual-energy X-ray absorptiometry of the rapid scan acquisition and central image. Areal bone
(DXA) is an ideal method for the accurate assessment of bone mineral density (aBMD) measurements (g/cm2 ) are based
mineral content (BMC) in pediatrics as radiation exposure is on a number of assumptions by DXA programs and are mis-
low and scan time is fast [1]. Despite the advantages of the leading as area is a two-dimensional assessment that does not
technology, DXA manufacturers have limited normal refer- account for the three-dimensional structure of bone. How-
ence values available for pediatric use and none for infants. ever, volumetric BMD (vBMD) can be estimated using DXA
There is a lack of consensus in the research area regard- with simple mathematical calculations that have been pro-
ing appropriate normative values for bone mineral content posed to overcome the problem of areal BMD, by eliminating
(BMC) of infants because of differences in age of infants, the effect of skeletal size [3]. Calculated vBMD in sexually
DXA manufacturers, and scan acquisition (Table 1). It is mature and immature primates [4] and adult humans [5]
clear that no one study has published on normative data agrees better with vBMD obtained from ash weight, the gold
collected longitudinally during infancy that includes both standard method of measuring true BMC, than aBMD. Thus,
whole body and regional assessments. For the accurate there remains a need for normal reference data of BMC as
interpretation of DXA data, there is a need for individual well as vBMD in healthy infants.
values to be expressed in relation to normative data. The objectives of this paper are to create a normative
The International Society for Clinical Densitometry reference data set for infants between birth to 12 mo of age
(ISCD) [2] supports the whole body and lumbar spine (LS) for the (i) BMC of whole body as well as lumbar spine and
 2

Table 1: Reference data on bone mineral measurements in healthy, term infants.

1 1 1
Reference Sample description Sample size BMC (g) Bone area (cm2 ) BMD (g/cm2 ) DXA manufacturer
Whole body
Venkataraman and Ahluwalia 1992 [43] 1.5 ± 0.1 d 28 80.05 ± 6.63 241.00 ± 13.00 0.324 ± 1.00 × 0.1−4 DXA (not specified)
0.2–0.5 mo 76.00 ± 14.00 0.237 ± 0.022
Atkinson et al., 1992 [21] 4 mo 87 147.00 ± 22.00 0.277 ± 0.028 Hologic QDR 1000W (IWB V.5.56P)
6 mo 190.00 ± 28.00 0.299 ± 0.031
1 mo 91.90 ± 14.10
Phase I 3 mo 92 123.05 ± 16.89
Specker et al., 19972 [44] 6 mo 161.78 ± 24.09
Hologic QDR 1000W (IWB V.5.56)
6 mo 161.99 ± 26.44
Phase II 9 mo 87 198.58 ± 28.74
12 mo 236.18 ± 35.78
1–8 d 65 68.20 ± 10.20 308.00 ± 26.40 0.221 ± 0.017
9–90 d 16 103.40 ± 21.40 431.00 ± 58.10 0.238 ± 0.022
Koo et al., 1998 [20] 91–150 d 17 137.10 ± 20.00 527.00 ± 45.40 0.259 ± 0.024 Hologic QDR 1000W
151–270 d 12 196.40 ± 26.60 650.00 ± 64.30 0.302 ± 0.018
271–390 d 20 253.20 ± 41.30 754.00 ± 87.80 0.335 ± 0.029
0.5 mo 43 68.00 ± 12.00
Girls
Butte et al, 2000 [45] 12 mo 42 208.00 ± 31.001
Hologic QDR 2000 (IWB 5.56–5.71P)
0.5 mo 33 68.00 ± 13.00
Boys
12 mo 32 221.00 ± 33.00
33 ± 4 d 37 82.60 ± 11.90 377.71 ± 36.60
63 ± 4 d 35 103.80 ± 16.00 437.24 ± 61.84
Avila-Dı́az et al., 2001 [19] 94 ± 11 d 29 111.00 ± 15.10 467.65 ± 39.29 Hologic R 1500 (IWB 5.67P)
126 ± 10 d 18 129.30 ± 17.70 499.26 ± 43.51
147 ± 6 d 16 134.00 ± 20.00 521.01 ± 46.00
Hammami et al., 2003 [46] 3.0 ± 2.1 d 73 89.30 ± 14.10 371.00 ± 32.70 0.240 ± 0.022 Hologic QDR 4500A
Lumbar spine
Braillon et al., 1992 [11] 1d 10 2.34 ± 0.42 0.268 ± 0.030 Hologic QDR 1000, L1-5
Kurl et al., 2002 [12] Girls 22 1.93 ± 0.57 8.27 ± 1.10 0.230 ± 0.050
2–6 mo Lunar DPX, L2-4 (IAP spine mode V.3.8E)
Boys 19 2.26 ± 0.58 8.74 ± 1.20 0.250 ± 0.040
Zia-Ullah et al., 2002 [13] 1–39 d 99 2.20 ± 1.50 8.80 ± 4.20 0.231 ± 0.049 Hologic QDR 1000W, L1-4
∗
BMC, bone area, and BMD reported as mean ± SD. WB: infant whole body, IAP: infant AP (front view).
1 2
Values are presented as per reported in original reference. Based on pooled average + SD from reported group mean, phase I (1–6 mo): human milk (n = 31), low mineral formula (Good Start; Carnation
Nutritional Products) (n = 30), moderate mineral formula (Similac; Ross Laboratories) (n = 31); phase II (6–12 mo): moderate mineral formula (Similac) (n = 38), high mineral formula (Carnation followup)
(n = 39), whole cow’s milk (n = 10).
Journal of Osteoporosis
Journal of Osteoporosis 3

femur and (ii) aBMD and vBMD of the lumbar spine. This left femur. To limit error, infants were scanned while asleep
data will ultimately aid in the interpretation of bone scans in in order to minimize the potential for movement artefact and
infants. maximize the probability that both regional and whole body
scans be performed with the infant in the same position.
2. Materials and Methods For all analyses, scans were not used if >2 line breaks were
observed or if the infant was positioned on his/her side or
2.1. Study Subjects. Infants were recruited from the Health stomach although the errors obtained in altered positioning
Sciences Center in Winnipeg, MB (latitude 49.54◦ N), from are considered small [6]. Each infant wore a single light
births delivered between August 2001 and April 2003. For sleeper with no metal or plastic components and a diaper;
entry to the study, an infant had to be born between infants were wrapped in a single receiving blanket. BMC was
37–42 weeks of gestation (based on ultrasound dating), expressed as absolute weight in grams. Areal BMD was cal-
appropriate birth weight for gestational age based on Center culated for lumbar spine by the DXA software as BMC
for Disease Control (CDC) 2000 growth charts (between 5– divided by projected area of the scan. Volumetric BMD was
95th percentile), and free of congenital malformations. Cord calculated using the Carter method [3] as aBMD divided by
blood and maternal blood (obtained at 0800 h within 48 the square root of the projected area. The CV for quality con-
hours of delivery) were collected into heparinized tubes, and trol measurements of BMC using a spine phantom (Hologic
plasma was separated from red blood cells (by centrifugation phantom number 8832) over the course of the study was
at 2000 ×g) followed by storage at −80◦ C until analysis. <1.0%. This same DXA machine was used as part of the
Follow-up visits were conducted within 2–4 weeks of birth Canadian Steroid-Associated Osteoporosis in the Pedia-
and at 6 and at 12 mo of age. The total cohort involved 72 tric Population (STOPP) study [7] which involved 10 tertiary
infants, but the current evaluation was limited to 63 infants children’s care centers across Canada between 2005 and
(36 boys, 27 girls) who completed at least 2 of the 3 scheduled 2007. A spine phantom (number S5550) was cross-calibrated
visits. At each visit, mothers were questioned about infant across study sites including the Manitoba Child Institute of
feeding practices (categorized as breastfed or formula fed) Child Health, and in vivo precision for LS BMD ranged from
and supplement use (taking vitamin D supplement or any 0.003 to 0.0173 g/cm2 .
other infant multimineral/vitamin). Vitamin D supplements
(Enfamil V-Di-Sol, 400 IU/1 mL) or infant formula (Enfalac 2.3. Vitamin D Measurements. To further describe the
standard term) were provided in kind by Mead-Johnson cohort, vitamin D was measured as 25-hydroxyvitamin D
depending on feeding type up to 1 year of age as per nutri- (25(OH)D) in cord plasma in duplicates using a radioim-
tional requirements (formula fed infants do not require vita- munoassay (Diasorin, Stillwater, MN). The assay was run in
min D supplementation). Mothers were asked to self-identify accordance with manufacturer’s specifications, with a coef-
their ethnicity, and season of birth was determined based on ficient of variation less than 10%. The vitamin D status of
the solstices and equinoxes of the current calendar year. The mothers and infants was categorized as deficient based on
study was approved by the ethical review board of the Univer- a plasma 25(OH)D concentration less than 37.5 nmol/L for
sity of Manitoba Ethics Review Board (Manitoba, Canada), mothers and less than 27.5 nmol/L for infants [8, 9].
and informed consent was obtained for all participants.
2.4. Sample Size Estimations. The primary objective of this
2.2. Anthropometric and BMC Measurements. At follow-up report is to describe the bone mass of infants over the
visits, weight was taken to the nearest gram using an elec- first year of life; thus, given our available sample size, the
tronic scale (model SB 32000, Mettler-Toledo Inc., Greifen- desired total width (margin of error) was estimated between
see, Switzerland), length to the nearest 0.1 cm using an infant the observed mean and the population mean. The desired
length board (O’Learly Length Boards, Ellard Instrument- sample total width was based on the following calculation:
ation Ltd., Seattle, WA), and head circumference to the W 2 = 4zα2 S2 /n [10], where zα2 = 95% confidence level, S =
nearest 0.1 cm using nonstretchable tape (Perspective Enter- standard deviation of spine bone mineral density from previ-
prises, Portage, MI). BMC of the whole body, lumbar spine ous studies (based on 0.132 g/cm2 ) [11–13], and W = width
(vertebrae 1–4), and femur was assessed by a certified bone of the margin of error. Based on our sample size of 63 infants,
densitometry technologist. Infants were scanned in array we are 95% confident that the true mean spine bone mineral
mode by DXA (QDR 11.2, QDR 4500A Elite, Hologic Inc., density of sampled infants is within 6.5% of the true popula-
Waltham, MA) for infant whole body software, anterior tion mean. However, the width of the confidence interval
posterior lumbar spine for vertebrae 1 to 4 using the AP spine for LS BMC (based on standard deviation of 0.77 g) was
software, and femur using left hip subregion analysis. While within 38% of the true population mean, and to decrease the
the lumbar spine scan is akin to that of adults, the femur scan margin of error to within 15%, the sample size would need
was of the whole femur from proximal to distal epiphyses to increase to 405 infants.
and analyzed as a whole bone to derive whole femur BMC.
The auto low density option was used for both spine and 2.5. Statistical Analyses. Descriptive results for continuous
femur detection and bone maps were manually traced. All variables are expressed as arithmetic mean (±SD). All BMC
scans were independently reviewed by two certified bone measurements were considered as continuous variables, and
densitometry technologists. Scans were typically performed differences compared among sex, feeding mode, and season
in the following order: whole body, lumbar spine, and the of birth were tested using Student’s t-test at each time
4 Journal of Osteoporosis

point. Differences in bone parameters over time were tested Table 2: Infant and maternal characteristics.
by one-way analysis of variance (ANOVA) with the Tukey Mean (± SD)
Characteristic
adjustment for multiple comparisons. Statistical significance
Gestational age, weeks 39.3 ± 1.1
was set at P ≤ 0.05, and all P values presented are two
tailed. Data was analyzed using Statistical Analysis System Weight-for-age percentile
(SAS) version 9.2 statistical software (SAS Institute Inc., (CDC 2000 growth charts) 52.1 ± 26.4
Cary, NC). A reference curve was generated for lumbar spine Feeding type, n (%)
18 (28.6)
BMD using the “LMS” method [14]. The curve was con- Formula
structed using LMS Chartmaker Pro (version 2.54; T Cole Breastfeed < 6 moψ 31 (49.2)
& H Pan, copyright 1997–2006, Medical Research Council, Breastfeed > 6 mo 14 (22.2)
UK). The LMS method fits 3 parameters (LMS) as cubic Season of birth, n (%)
splines by nonlinear regression [14, 15]. The 3 parameters Summer/fall 32 (50.8)
represent the median (M), SD (S), and power in the Box-Cox Winter/spring 31 (49.2)
transformation (L) that vary as a function of age using the
Infant’s vitamin D status
following formula: BMD centile = M(1+L · S · Z)1/L [14, 15],
where L, M, S are age-specific and Z is the Z-score that Deficient1 19 (30.2)
corresponds to a given percentile. Fit of the curves was eval- Sufficient 44 (69.8)
uated by graphical inspection of the curves relative to the raw Mother’s age at birth, years 27.7 ± 6.1
data and by Q-Q plots. Mother’s race, n (%)
White 41 (65.1)
3. Results First nations 10 (15.9)
Asian 7 (11.1)
3.1. Subject Characteristics. Subject and maternal character-
istics are presented in Table 2. At birth, the mean gestational Black 2 (3.2)
age of infants was 39 (±1) wk and weight-for-age percentile Other 3 (4.8)
was 52.1 (±26.4) in accordance with inclusion criteria. Based Mother’s vitamin D status
on self-reports, approximately 29% of infants were formula Deficient2 23 (36.5)
fed from birth, 49% were breastfed for less than 6 mo, and Sufficient 40 (63.5)
22% were breastfed for longer than 6 mo. Mother’s age at 1 2
Infant: 25(OH)D ≤ 27.5 nmol/L, Mother: 25(OH)D ≤ 37.5 nmol/L—
birth was 28 (±6) y. The majority of mothers self-identified Institute of medicine dietary reference intakes [8, 9]. ψMay include exclusive
their race as being white (65%), 16% were of First Nations breastfeeding and mixed feeding. Exclusive breastfeeding refers to an infant
status, 3% were black, and the remainder were of other receiving only breast milk without additional liquid or solid food.
ethnicity (Hispanic, East Asian, etc.). Season of birth was
equally divided among all participants, 51% of infants were
born during the summer/fall, and 49% were born during the by feeding mode. As well, there were differences noted in
winter/spring months. Plasma 25(OH)D was <27.5 nmol/L both spine BMC at term by season of birth; spring babies had
in 19 (30%) infants and <37.5 nmol/L in 23 (37%) mothers. higher (P < 0.05) spine BMC (2.51 ± 0.39 g) than fall babies
(2.07 ± 0.33 g). These differences did not persist at 6 and
3.2. Bone Mineral Content. Mean BMC of whole body, 12 mo of age. Ethnicity and race differences were not consid-
lumbar spine, and femur at term and 6 and 12 mo is shown ered because of the limited number of participants in each
in Table 3. There was a rapid increase of 123% in whole category.
body BMC up to 6 mo from term (P < 0.01), and this rate
slows to a 34% increase from 6 to 12 mo of age. There were 3.3. Spine Bone Mineral Density. Mean BMD of lumbar
significant sex differences for whole body BMC noted at 6 mo spine at term and 6 and 12 mo is shown in Table 3. Spine
of age (P < 0.01) between boys (184.49 ± 27.09 g) and girls BMD decreased by 5% from term to 6 mo of age and then
(149.46 ± 17.22 g) which disappeared at 12 mo of age. Femur increased by 21% from 6 to 12 mo of age. No significant
BMC grows rapidly from 6 mo of age (at an increase of 90% differences were noted at each time point according to sex
from term to 6 mo and 52% from 6 to 12 mo), whereas or infant’s vitamin D status at birth (deficient/sufficient).
spine BMC increases more linearly over the first year. Signi- However, there were significant differences (P < 0.01) in
ficant differences were observed between boys (3.81 ± 0.59 g; spine BMD at the 12 mo time point between infants which
5.65 ± 1.03 g) and girls (3.30 ± 0.56 g; 5.02 ± 0.91 g) at both were formula fed (0.328 ± 0.040 g/cm2 ) and those breastfed
6 (P < 0.01) and 12 mo (P < 0.05), respectively, for spine (0.293 ± 0.043 g/cm2 ). As well, spring babies had higher
BMC. Similarly, there were significant differences between (P < 0.05) spine BMD (0.290 ± 0.038 g/cm2 ) than fall babies
boys (8.97 ± 1.79 g) and girls (7.90 ± 1.75 g) at 12 mo (P < (0.248 ± 0.037 g/cm2 ). The final smoothed percentile curve
0.05) for femur BMC. There were significant differences (P < for spine aBMD is shown in Figure 1 depicting the 3, 10, 25,
0.05) in spine BMC at both 6 and 12 mo between infants 50, 75, 90, and 97th percentiles.
which were formula fed (3.81 ± 0.63 g; 5.79 ± 0.90 g) and Volumetric BMD was calculated for lumbar spine
those breastfed for at least 1 mo (3.48 ± 0.60 g; 5.18 ± 1.02 g), (Table 3). During the first 6 mo, there appears to be a
respectively, but no differences were detected in femur BMC decrease in vBMD followed by stabilization up to 12 mo.
Journal of Osteoporosis 5

Table 3: Mean ± SD (n) bone mineral content of whole body, femur, lumbar spine, and bone area, areal bone mineral density, and volumetric
bone mineral density of the lumbar spine from birth to 12 mo of age in term infants. Means with different superscript letters indicate
statistically significant differences between time points (P < 0.05, post-Tukey adjustment).

Site Term 6 mo 12 mo
Total WB BMC, g 75.98 ± 14.17a (52) 169.48 ± 29.01b (35) 227.0 ± 29.73c (11)
Total WB BMC/body weight, g/kg 20.71 ± 2.49a (52) 21.41 ± 1.89a (35) 23.39 ± 1.17b (11)
WB BMC less head, g 43.58 ± 8.13a (52) 87.66 ± 16.32b (35) 114.8 ± 21.86c (11)
WB BMC less head/body weight, g/kg 11.89 ± 1.59a (52) 11.04 ± 1.08b (35) 11.75 ± 0.75a,b (11)
Femur BMC, g 2.94 ± 0.54a (61) 5.58 ± 1.46b (60) 8.50 ± 1.84c (54)
Lumbar spine BMC, g 2.35 ± 0.42a (62) 3.59 ± 0.63b (62) 5.37 ± 1.02c (57)
Lumbar spine area, cm2 8.86 ± 1.10a (62) 14.28 ± 2.01b (62) 17.67 ± 2.52c (57)
Lumbar spine areal BMD, g/cm2 0.266 ± 0.044a (62) 0.252 ± 0.031a (62) 0.304 ± 0.044b (57)
Lumbar spine volumetric BMD, g/cm3 0.090 ± 0.017a (62) 0.067 ± 0.010b (62) 0.073 ± 0.012b (57)

0.4
97th
rendering the whole body scan unusable [20]. While our data
90th for whole body BMC is robust up to 6 mo, it is not reliable
Lumbar spine BMD (g/cm2 )

0.35
75th beyond the 6 mo time point because of our limited sample
0.3 50th size due to movement artefact. The data on whole body BMC
25th up to 6 mo was consistent with previous researchers who
0.25 10th tracked 87 term infants until 6 mo [21]. Due to the variability
3rd
0.2 in obtaining a scan for whole body measurements, regional
sites may have more clinical utility. Although data is available
0.15 for spine measurements using DXA, the previously published
0.1
data consist mostly of cross-sectional studies. Thus, this
present work provides much needed data on healthy infants
0 60 120 180 240 300 360 followed longitudinally in the first year of life.
Age (d) Lumbar spine vertebra is the easiest measurement site
to obtain in infants because it is less subject to movement
Figure 1: Spine BMD-for-age reference curve for infants, birth to artefact while providing minimal effective dose of radiation
12 mo.
[22]. Although validation studies for the lumbar spine are
not available on the QDR 4500A, precision for lumbar spine
The spine vBMD measurement was not subject to gender measurements in infants has also been reported to be good
differences, as well, there were no differences according to in an older model with a coefficient of variation of 2.4% and
infant’s vitamin D status at birth. Similar to aBMD, there 1.55% for BMC and BMD, respectively [11]. In addition,
were significant differences (P < 0.05) in spine vBMD at spine is formed mainly by trabecular bone, and the rate of
12 mo between infants which were formula fed (0.079 ± bone turnover in the trabecular compartment is much more
0.01 g/cm3 ) and those breastfed (0.070 ± 0.01 g/cm3 ). rapid than in the cortical area, thus, allowing for better track-
ing of bone changes in clinical trials. Thus, rates of change in
4. Discussion bone density will be greater in sites that are predominately
trabecular bone such as the spine. The previous literature
The ISCD recommends spine and whole body as the pre- on lumbar spine bone mineral mass is inconsistent because
ferred scan sites for the diagnosis of bone diseases in children of the use of different vertebrae for analysis; however, the
[2, 16]; however, presently no specific recommendations most recent publications have focused on lumbar vertebrae
exist for infants. In infants, the head can represent up to 1–4 [13, 23]. While spine BMC is the most easily obtained
50% of total BMC, and due to inaccuracies in the algorithm measurement, it seems to have the lowest rate of accretion
for determining skull BMC [17], the use of the whole body over the first year. Even for BMD, increments were only 14%
less head measurement may be preferred. As infants grow, it suggesting that growth and mineral accretion is lower during
becomes increasingly difficult for them to fall asleep on the this time compared to the long bones.
DXA bed making the whole body assessment challenging to Not much is known about infant femur BMC, and this
attain because of movement artefact. The challenge is even study provides extended knowledge in this area. Cortical
greater when you have a child with contractures, mental bone mass is lower in infants born small-for-gestational-age
impairment, or other impediments to scanning which is of compared to appropriate-for-gestational-age infants [24].
importance as these children may have conditions which pre- Although DXA cannot distinguish between cortical and
dispose them to low bone density [18]. Observations from trabecular bone mass, the content of cortical bone is higher
previous research utilizing pediatric DXA had similar sample in the femur than in the spine. Interestingly, Weiler et al. [25]
size reductions with increasing age [19, 20]. In one study, found premature infants born with very low birth weight
movement artefact was reported in 20% of infants scanned (≤1200 g) who were supplemented with early minimal
6 Journal of Osteoporosis

enteral feeds had higher elevations in femur bone mass of infant feeding can have an important influence on growth
(36%) compared to spine bone mass (16%). In these infants and body composition [39]. Our data corroborate these
[25], femur responded to a greater extent than spine and findings as we found that being formula fed had a significant
may prove valuable in assessing response to treatment. In effect on the aBMD of the spine by 12 mo of age. The differ-
addition, Lu et al. [26] observed that vBMD of the femur and ences in bone mass noted between sexes may be related to
not the lumbar spine was less dependent on growth variables differences in growth as anthropometric characteristics were
in their study with children and young adults. significantly different at each time point; however, there were
The Carter method for the calculation of vBMD has no growth differences between the feeding groups. Accord-
been widely used in adults [27–29] and is being increasingly ing to Statistics Canada’s 2003 Canadian Community Health
recognized for use with children [30, 31]. Much of this data Survey (CCHS) [40], approximately 85% of Canadian
has been derived from pencil beam DXA systems [27, 29], women attempted breastfeeding and 47% did so for longer
and new fan-beam systems have shown improvements over than 6 mo. In our group, approximately 71% were breast fed
pencil beam technology [32, 33]. However, the objective for at least 1 mo of age of which 31% were breastfeeding for
of reporting this calculated value using our dataset was to longer than 6 mo. Therefore, the present data set provides a
provide reference data for those clinicians who favor this representative sample of breast-fed and formula-fed infants
approach while acknowledging that validation studies have in keeping with current Canadian statistics. Although a vita-
found conflicting results. In cadavers of older adults, vBMD min D supplement was provided to all participating breast-
was estimated from an equation similar to the Carter method feeding mothers in this study, compliance data was self-
and was strongly correlated with true vBMD calculated by reported. An optimal growth reference should be based on a
dividing ash weight by CT-derived volume (r 2 = 0.94) group of healthy, breast-fed infants receiving vitamin D sup-
[34]. In children and adolescents, volumetric adjustments plementation.
improved only slightly the correlation with CT-measured There are limitations with this data because it is not
vBMD (r 2 = 0.13 and 0.60 from r 2 = 0.02 and 0.51 in Tanner based on a nationally representative sample and observations
stages 1–3 and 4-5, resp.) [35]. Although this method has were recorded at 6 mo intervals during the first year. Infants
been used in infancy [35], it has not been validated in this were recruited solely from Winnipeg, MB, which is located at
population group. It has been suggested that, using an aver- the 49th parallel north and in south central Canada. None-
age of anterior posterior (AP), lumbar spine and lateral ver- theless, our results were similar to those obtained in southern
tebral scans can approximate vBMD because it makes asses- Ontario [21]. Furthermore, the prevalence of maternal
sments of vertebral height, width, and depth. Even in infants vitamin D deficiency from this group was similar to that
with osteopetrosis, which causes an increase in bone mass, reported from other Canadian studies [41, 42]. Future
the average AP and lateral spine measurements correlated research should seek pooled data from cross country sites
well with CT measures of BMD (r 2 = 0.851, P < 0.001) [36]. with observations recorded at 1–3 mo intervals to create a
In an older group, a comparison of paired AP lateral spine combined bone mass percentile chart data set.
and estimated vBMD using the Carter method found a signi- In summary, DXA is a valuable tool for the screening and
ficant correlation of r = 0.81 [37]. Although considered indi- diagnosis of pediatric bone diseases. This data provides the
rectly, this implies that estimated vBMD values show pro- foundation for future research, but also provides important
mise even though this remains to be directly validated reference data not currently available, for infants on femur
against CT in infants. In our study, spine vBMD decreases BMC and vBMD. This in addition to clinical data will ulti-
during the first 6 mo because this is a period of rapid bone mately aid in the diagnosis, interpretation, and response to
modeling and the bone is mineralizing at a slower rate treatment for pediatric bone diseases.
than the bone is growing. This is a normal phenomenon
as previously observed [38] and is not a sign of bone loss. Acknowledgments
The mineralization starts to catch up by 6 mo, and vBMD
remains fairly stable up to 12 mo. Volumetric BMD of the This work was supported by a grant from the Canadian Insti-
spine may become a preferred assessment site because it is tutes of Health Research. S. Gallo was the primary author
also not subject to gender differences in infancy. for the paper. S. Gallo performed statistical analyses and
Percentile curves for growth have been widely used to made major data interpretations. C. A. Vanstone conducted
assess the nutritional status and general health of infants, analyses of all DXA scans. H. A. Weiler provided assist-
children, and adolescents. Bone mass data assessed by DXA ance with the implementation of the study as well as con-
is limited in healthy, term infants, and at present there is sultation for statistical analyses and data interpretations. H.
no available data that presents normative bone mass mea- A. Weiler and C. A. Vanstone provided editorial revisions
surements for infants using percentile charts. The percentile for the paper. H. A. Weiler was the principal investigator for
chart that was constructed for spine bone mineral density is the research project and provided access to the study data-
displayed to show a possible alternative way to illustrate nor- base. None of the authors had any financial or personal con-
mative data. Presenting data in this manner will help health flicts of interests. These results were presented in part at
care professionals and clinical researchers plot infants and the 2008 Experimental Biology conference (San Diego, CA).
compare to healthy infants of the same age and gender, thus The authors wish to thank Mrs. Shirley C. Fitzpatrick-Wong
determining adequacy. Larger datasets using prospectively and Mrs. Jeannine M. Schellenberg for their help with data
collected data can be utilized in the same manner [14]. Mode collection as well as the Newborn Units at the Women’s
Journal of Osteoporosis 7

Hospital (Winnipeg, MB) and the research group at Uni- [14] T. J. Cole and P. J. Green, “Smoothing reference centile
versity of Manitoba (R. Veitch, H. Kovacs, U. McCloy, D. curves: the LMS method and penalized likelihood,” Statistics
Fair) for their help with interviews and coordination of the in Medicine, vol. 11, no. 10, pp. 1305–1319, 1992.
study. [15] B. S. Zemel, V. A. Stallings, M. B. Leonard et al., “Revised
pediatric reference data for the lateral distal femur measured
by Hologic Discovery/Delphi dual-energy X-ray absorptiom-
References etry,” Journal of Clinical Densitometry, vol. 12, no. 2, pp. 207–
218, 2009.
[1] S. Mora, L. Bachrach, and V. Gilsanz, “Noninvasive techniques [16] C. M. Gordon, L. K. Bachrach, T. O. Carpenter et al., “Dual
for bone mass measurement,” in Pediatric Bone: Biology and energy X-ray absorptiometry interpretation and reporting in
Diseases, F. Glorieux, J. Pettifor, and H. Juppner, Eds., pp. 303– children and adolescents: the 2007 ISCD pediatric official
324, Academic Press, San Diego, Calif, USA, 2003. positions,” Journal of Clinical Densitometry, vol. 11, no. 1, pp.
[2] N. Binkley, J. P. Bilezikian, D. L. Kendler, E. S. Leib, E. M. 43–58, 2008.
Lewiecki, and S. M. Petak, “Official Positions of the Inter- [17] A. Taylor, P. T. Konrad, M. E. Norman, and H. T. Harcke,
national Society for Clinical Densitometry and Executive “Total body bone mineral density in young children: influence
Summary of the 2005 Position Development Conference,” of head bone mineral density,” Journal of Bone and Mineral
Journal of Clinical Densitometry, vol. 9, no. 1, pp. 4–14, 2006. Research, vol. 12, no. 4, pp. 652–655, 1997.
[3] D. R. Carter, M. L. Bouxsein, and R. Marcus, “New approaches [18] E. A. Szalay and D. Harriman, “Adapting pediatric DXA scan-
for interpreting projected bone densitometry data,” Journal of ning to clinical orthopaedics,” Journal of Pediatric Orthopa-
Bone and Mineral Research, vol. 7, no. 2, pp. 137–145, 1992. edics, vol. 26, no. 5, pp. 686–690, 2006.
[4] S. M. Ott, M. O’Hanlan, E. W. Lipkin, and L. Newell-Morris, [19] M. Avila-Dı́az, S. Flores-Huerta, I. Martı́nez-Muñiz, and D.
“Evaluation of vertebral volumetric versus areal bone mineral Amato, “Increments in whole body bone mineral content
density during growth,” Bone, vol. 20, no. 6, pp. 553–556, associated with weight and length in pre-term and full-trerm
1997. infants during the first 6 months of life,” Archives of Medical
[5] M. A. Sabin, G. M. Blake, S. M. MacLaughlin-Black, and I. Research, vol. 32, no. 4, pp. 288–292, 2001.
Fogelman, “The accuracy of volumetric bone density mea- [20] W. W. K. Koo, A. J. Bush, J. Walters, and S. E. Carlson, “Postna-
surements in dual X-ray absorptiometry,” Calcified Tissue tal development of bone mineral status during infancy,” Jour-
International, vol. 56, no. 3, pp. 210–214, 1995. nal of the American College of Nutrition, vol. 17, no. 1, pp. 65–
[6] R. C. Henderson, R. K. Lark, J. B. Renner et al., “Dual X-ray 70, 1998.
absorptiometry assessment of body composition in children [21] S. Atkinson et al., “Pattern of growth and body composition
with altered body posture,” Journal of Clinical Densitometry, in premature compared to term infants from term to six
vol. 4, no. 4, pp. 325–335, 2001. months,” The FASEB Journal, vol. 8, p. A278, 1994.
[7] J. Halton, I. Gaboury, R. Grant et al., “Advanced vertebral [22] S. R. Thomas, H. J. Kalkwarf, D. D. Buckley, and J. E. Heubi,
fracture among newly diagnosed children with acute lympho- “Effective dose of dual-energy X-ray absorptiometry scans in
blastic leukemia: results of the Canadian Steroid-Associated children as a function of age,” Journal of Clinical Densitometry,
Osteoporosis in the Pediatric Population (STOPP) research vol. 8, no. 4, pp. 415–422, 2005.
program,” Journal of Bone and Mineral Research, vol. 24, no. [23] C. M. Smith, R. C. Coombs, A. T. Gibson, and R. Eastell, “Ada-
7, pp. 1326–1334, 2009. ptation of the Carter method to adjust lumbar spine bone
[8] IOM (Institute of Medicine), Dietary Reference Intakes for mineral content for age and body size: application to children
Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride, who were born preterm,” Journal of Clinical Densitometry, vol.
The National Academies Press, Washington, DC, USA, 1997. 9, no. 1, pp. 114–119, 2006.
[9] IOM (Institute of Medicine), Dietary Reference Intakes for Cal- [24] J. Palacios, S. Rodriguez, and J. I. Rodriguez, “Intra-uterine
cium and Vitamin D, The National Academies Press, Washing- long bone growth in small-for-gestational-age infants,” Euro-
ton, DC, USA, 2011. pean Journal of Pediatrics, vol. 151, no. 4, pp. 304–307, 1992.
[10] W. Browner, S. R. Cummings, S. B. Hulley, and T. B. New- [25] H. A. Weiler, S. C. Fitzpatrick-Wong, J. M. Schellenberg et al.,
man, “Estimating sample size and power: the nitty-gritty,” “Minimal enteral feeding within 3 d of birth in prematurely
in Designing Clinical Research: An Epidemiologic Approach, S. born infants with birth weight ≤ 1200 g improves bone mass
Hulley, Ed., Lippincott Williams and Wilkins, Philadelphia, by term age,” American Journal of Clinical Nutrition, vol. 83,
Pa, USA, 2001. no. 1, pp. 155–162, 2006.
[11] P. M. Braillon, B. L. Salle, J. Brunet, F. H. Glorieux, P. D. [26] P. W. Lu, C. T. Cowell, S. A. Lloyd-Jones, J. N. Briody, and R.
Delmas, and P. J. Meunier, “Dual energy x-ray absorptiometry Howman-Giles, “Volumetric bone mineral density in normal
measurement of bone mineral content in newborns: valida- subjects, aged 5–27 years,” Journal of Clinical Endocrinology
tion of the technique,” Pediatric Research, vol. 32, no. 1, pp. and Metabolism, vol. 81, no. 4, pp. 1586–1590, 1996.
77–80, 1992. [27] S. Cvijetić and M. Koršić, “Apparent bone mineral density
[12] S. Kurl, K. Heinonen, J. S. Jurvelin, and E. Länsimies, “Lumbar estimated from DXA in healthy men and women,” Osteoporosis
bone mineral content and density measured using a Lunar International, vol. 15, no. 4, pp. 295–300, 2004.
DPX densitometer in healthy full-term infants during the first [28] E. D. Daniels, J. M. Pettifor, C. M. Schnitzler, G. P. Moodley,
year of life,” Clinical Physiology and Functional Imaging, vol. and D. Zachen, “Differences in mineral homeostasis, volumet-
22, no. 3, pp. 222–225, 2002. ric bone mass and femoral neck axis length in black and white
[13] M. Zia-Ullah, W. W. K. Koo, and M. Hammami, “Lumbar South African women,” Osteoporosis International, vol. 7, no.
spine bone measurements in infants: whole-body vs lumbar 2, pp. 105–112, 1997.
spine dual X-ray absorptiometry scans,” Journal of Clinical [29] S. Khosla, E. J. Atkinson, B. L. Riggs, and L. J. Melton,
Densitometry, vol. 5, no. 1, pp. 17–25, 2002. “Relationship between body composition and bone mass in
8 Journal of Osteoporosis

women,” Journal of Bone and Mineral Research, vol. 11, no. 6, updated reference,” Pediatric Research, vol. 47, no. 5, pp. 578–
pp. 857–863, 1996. 585, 2000.
[30] L. A. Binkovitz, M. J. Henwood, and P. Sparke, “Pediatric [46] M. Hammami, W. W. K. Koo, and E. M. Hockman, “Body
DXA: technique, interpretation and clinical applications,” Ped- composition of neonates from fan beam dual energy X-
iatric Radiology, vol. 38, supplement 2, pp. S227–S239, 2008. ray absorptiometry measurement,” Journal of Parenteral and
[31] V. Gilsanz and T. Wren, “Assessment of bone acquisition in Enteral Nutrition, vol. 27, no. 6, pp. 423–426, 2003.
childhood and adolescence,” Pediatrics, vol. 119, supplement
2, pp. S145–S149, 2007.
[32] P. Tothill, W. J. Hannan, and S. Wilkinson, “Comparisons
between a pencil beam and two fan beam dual energy X-ray
absorptiometers used for measuring total body bone and soft
tissue,” British Journal of Radiology, vol. 74, no. 878, pp. 166–
176, 2001.
[33] R. J. Toombs, G. Ducher, J. A. Shepherd, and M. J. De Souza,
“The impact of recent technological advances on the trueness
and precision of DXA to assess body composition,” Obesity,
vol. 20, no. 1, pp. 30–39, 2012.
[34] M. M. Sran, K. M. Khan, K. Keiver, J. B. Chew, H. A. McKay,
and T. R. Oxland, “Accuracy of DXA scanning of the thoracic
spine: cadaveric studies comparing BMC, areal BMD and
geometric estimates of volumetric BMD against ash weight
and CT measures of bone volume,” European Spine Journal,
vol. 14, no. 10, pp. 971–976, 2005.
[35] T. A. L. Wren, X. Liu, P. Pitukcheewanont, and V. Gilsanz,
“Bone acquisition in healthy children and adolescents: com-
parisons of dual-energy X-ray absorptiometry and computed
tomography measures,” Journal of Clinical Endocrinology and
Metabolism, vol. 90, no. 4, pp. 1925–1928, 2005.
[36] S. C. Kaste, K. A. Kasow, and E. M. Horwitz, “Quantitative
bone mineral density assessment in malignant infantile osteo-
petrosis,” Pediatric Blood and Cancer, vol. 48, no. 2, pp. 181–
185, 2007.
[37] M. B. Leonard, J. Shults, and B. S. Zemel, “DXA estimates
of vertebral volumetric bone mineral density in children:
potential advantages of paired posteroanterior and lateral
scans,” Journal of Clinical Densitometry, vol. 9, no. 3, pp. 265–
273, 2006.
[38] F. Rauch and E. Schoenau, “Changes in bone density during
childhood and adolescence: an approach based on bone’s
biological organization,” Journal of Bone and Mineral Research,
vol. 16, no. 4, pp. 597–604, 2001.
[39] N. F. Butte, W. W. Wong, J. M. Hopkinson, E. Smith, and K.
J. Ellis, “Infant feeding mode affects early growth and body
composition,” Pediatrics, vol. 106, no. 6, pp. 1355–1366, 2000.
[40] W. Millar and H. Maclean, “Breastfeeding practices,” Health
Reports, vol. 16, no. 2, pp. 23–31, 2005.
[41] D. Rucker, J. A. Allan, G. H. Fick, and D. A. Hanley, “Vitamin
D insufficiency in a population of healthy western Canadians,”
Canadian Medical Association Journal, vol. 166, no. 12, pp.
1517–1524, 2002.
[42] R. Vieth, D. E. Cole, G. A. Hawker, H. M. Trang, and L. A.
Rubin, “Wintertime vitamin D insufficiency is common in
young Canadian women, and their vitamin D intake does not
prevent it,” European Journal of Clinical Nutrition, vol. 55, no.
12, pp. 1091–1097, 2001.
[43] P. S. Venkataraman and B. W. Ahluwalia, “Total bone mineral
content and body composition by X-ray densitometry in
newborns,” Pediatrics, vol. 90, no. 5 I, pp. 767–770, 1992.
[44] B. L. Specker, A. Beck, H. Kalkwarf, and M. Ho, “Randomized
trial of varying mineral intake on total body bone mineral
accretion during the first year of life,” Pediatrics, vol. 99, no.
6, p. E12, 1997.
[45] N. F. Butte, J. M. Hopkinson, W. W. Wong, E. O. Smith, and
K. J. Ellis, “Body composition during the first 2 years of life: an