Alexandra K. Sarkis, University of Florida College of Medicine, Gainesville, FL, United States; Michael Elias, University of Florida College of Medicine, MIami, FL, United States; Kelli Stewart, UF Health Shands Children's Hospital, Newberry, FL, United States; Alexis Speed, UF Health, Gainesville, FL, United States; Katherine Kisilewicz, UF Health, Gainesville, FL, United States; Khang Tran, UF Health Shands Children's Hospital, Gainesville, FL, United States; Josef Neu, University of Florida, Gainesville, FL, United States; Diomel DE LA CRUZ, University of Florida, Gainesville, FL, United States
Fellow University of Florida College of Medicine MIami, Florida, United States
Background: Metabolic bone disease (MBD) of prematurity is a frequent and underrecognized condition among very low birth weight (VLBW) infants, caused by insufficient calcium and phosphorus accretion during a critical phase of skeletal growth. It is defined by elevated alkaline phosphatase (>800 IU/L) and low serum phosphorus ( < 4.0–5.6 mg/dL), leading to demineralization, fractures, and poor postnatal growth. Risk increases with limited mineral stores at birth, prolonged parenteral nutrition, delayed enteral feeding, and medication exposures that alter bone metabolism. Early detection and standardized management are essential to prevent long-term skeletal complications. Objective: To assess the impact of implementing a standardized UF MBD Prevention Guideline on mineral delivery, surveillance, and prevention of metabolic bone disease in preterm infants. Design/Methods: This quality improvement project was conducted in a Level IV NICU and included infants < 1500 g or < 30 weeks’ gestation. A multidisciplinary team of neonatologists, dietitians, pharmacists, nurses, and pediatric subspecialists created an evidence-based guideline specifying nutritional targets (calcium 150–200 mg/kg/day, phosphorus ≥100 mg/kg/day, vitamin D 400 IU/day), laboratory monitoring, and escalation steps. Biweekly interdisciplinary nutrition meetings reviewed progress and addressed implementation barriers. The guideline was introduced through education, visual cues, and workflow integration (Figure 1). Pre-implementation data (Feb–Aug 2025) provided baseline performance, while Cycle 1 (Aug–Oct 2025) tracked nutrient intake using electronic records. Results: At two weeks, 78%, 54%, and 68% of infants met calcium, phosphorus, and vitamin D goals before implementation versus 60%, 47%, and 67% after rollout, establishing baseline variation. By one month, adequacy for calcium and vitamin D improved to 90–92% and 87–92%, reflecting more consistent feeding and supplementation. Phosphorus intake increased gradually during the transition. At two months, 100% achieved calcium, phosphorus, and vitamin D targets compared with 89%, 74%, and 100% before (Figure 2). No adverse trends or fractures were observed.
Conclusion(s): Implementation of a multidisciplinary, evidence-based MBD guideline improved mineral delivery, surveillance, and standardization of care. Early results show enhanced adherence, better phosphorus correction, and strong potential for sustained improvement.
Figure 1. Figure 1.pdfFigure 1. UF Metabolic Bone Disease (MBD) Prevention Guideline algorithm illustrating prevention, surveillance, and intervention pathways for very low birth weight ( <1500 g) and preterm ( <30 weeks’ gestation) infants.
Figure 2 Figure 2.jpegFigure 2. Percentage of infants meeting calcium, phosphorus, and vitamin D intake targets before (Figure 2a) and after (Figure 2b) implementation of the Metabolic Bone Disease (MBD) Prevention Guideline. The x-axis represents postnatal time points (2 weeks, 1 month, and 2 months), and the y-axis shows the percentage of infants meeting each nutrient goal.
