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H ILD OO H D Complete, balanced nutrition C FRANCISCO J. ROSALES, M.D., SC.D., GROWTH & for healthy : Gains in Medical Director, Abbott Nutrition, Scientific NUTRITION and Medical Affairs E X S length and strength. P E RT

SCIENTIFIC OVERVIEW

Bone is a dynamic and highly specialized connective tissue, Figure 1 Articular characterized by interstitial growth through the action of chondrocytes at the growth plate,1 and by appositional growth Epiphyseal growth Growth in cartilage produced by periosteal osteoblasts. (fig 1) The two mechanisms surrounding epiphysis Cartilage replaced are different: interstitial growth provides growth in body by bone Bone remodeled length/height, while appositional growth provides thickness and Growth in length Cartilage growth enhances bone density and stability so bones will not break. in epiphyseal plate These two processes result in , increasing length Cartilage growth replaced by bone and strength while reducing the risk of stunting, and Bone remodeled 2 . Growth in diameter Bone addition Nutrition plays a key role in both mechanisms. It supplies the Bone resorption required intakes of type I and II nutrients like energy, amino GROWING BONE ADULT BONE acids and bone-forming minerals (Ca, P, Mg, Zn) and of other ions (i.e. Cu, Mn, carbonate, citrate) and vitamins (i.e. vitamins C, D, K). 2,3 These nutrients contribute to bone mineralization and peak bone mass, which play important roles in lifelong skeletal health.4 Complete, balanced nutrition is important in childhood and adolescence because these are the periods where most rapid skeletal development occurs, accounting for 30-40% of the total bone mass increase5 and 60 to >75% of adult height gained.6

Maintaining adequate intakes of calories and nutrients like protein, calcium, /K during childhood and adolescence are necessary to attain bone health. Ensuring normal bone density with peak bone mass should be a priority when dealing with children and adolescents.

APPLYING TO YOUR PRACTICE KEY TAKEAWAYS

• For children under 10 who are Figure 2 ONS EFFICACY ON CATCH-UP GROWTH IN HEIGHT • Complete, balanced nutrition is important for Change in cm from baseline growth faltering or at risk of bone health. 3 Dietary- * Counseling undernutrition it is possible 2.5 Alone ONS + Dietary 2 • There are two phases of significant [rapid] that diet alone or nutritional * Counseling counseling alone may not 1.5 skeletal development – childhood and * provide adequate intakes of 1 adolescence. 7,8,9 (fig 2) 0.5

bone-related nutrients. BASELINE (cm) CHANGE FROM 0 30 DAYS 60 DAYS 90 DAYS • If growth faltering or malnutrition occurs in • Consider the use of an Oral From: Alarcon PA. et. al. Clin Pediatr. 2003;42:209-217 children under 10, consider the use of an Nutritional Supplement (ONS) to fill key caloric and nutrient intake gaps in these patients ONS formulated at a caloric density of 1.0 kcal/mL that meets growth and development • When selecting an ONS, choose one formulated to reflect the reference values for macro- needs of these children. and micronutrients designed to meet the needs of the child patient population under 10.

References: 1. Pazzaglia UE1 et al., Fetal Pediatr Pathol. 2011;30(3):199-208 2. Prentice A et al. Proc Nutr Soc. 2006;65(4):348-60. 3. Golden MH. Acta Paediatr Scand Suppl. 1991;374:95-110. 4. Stagi S et al., Clin Cases Miner Bone Metab. 2013;10(3):172-9. 5. Holroyd C et al., . Int. 2012;23:401-10. 6. Kuczmarski RJ et al., Vital Health Stat 11(246). 2002 7. Greer FR et al., Pediatrics. 2006;117(2):578-85 8. Fatima S, et al., Clin Nutr. 2018;37(3):858-863. 9. Lazzerini M et al., Cochrane Database Syst Rev. 2013 21;(6):CD009584.

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