Neonatal transient hypophosphatemic hypercalciuric rickets in dizygous twins: A role for maternal alendronate therapy before pregnancy or antireflux medications?

BACKGROUND: Bisphosphonates (BP) are sometimes used in children and young women, but their use requires expertise and caution due to the relative lack of long-term efficacy and safety data. CLINICAL CASES: We report on two dizygotic male twins with a past of mild prematurity who presented at the age of 2 months with moderate clinical craniotabes, hypophosphatemia, normal circulating calcium, severe hypercalciuria, and low parathyroid hormone levels. Following supplementation with oral phosphorus and native vitamin D, the clinical and biological abnormalities disappeared within 2 months. Since the twins were dizygotic and were identical in terms of clinical presentation and progression, the only likely explanation for these transient mineral abnormalities was prenatal or neonatal exposure to a toxic agent. Taking into account their medical past, two drugs were possibly involved: either oral alendronate that their mother had received before pregnancy for misdiagnosed osteoporosis or antireflux medications, or both. DISCUSSION: We believe that these two cases could correspond to the first description of a potential mother-to-fetus transmission of alendronate, inducing early and transient hypophosphatemic rickets, the clinical picture being worsened by the antireflux drugs impairing intestinal phosphate absorption. For pediatric rheumatologists, this raises the question of more clearly defining the indications for BP in female children and teenagers; for rheumatologists, this also demonstrates the importance of correctly diagnosing osteoporosis and not using BP off-label, especially in women of child-bearing age.

[Epidemiology and evaluation of withdrawing and withholding of treatment procedure in a pediatric intensive care unit]. / Épidémiologie et évaluation des procédures de limitation et d'arrêt des traitements de maintien des fonctions vitales en réanimation pédiatrique.

OBJECTIVES: Leonetti Law of 2005 concerns procedures for questioning about the appropriateness of initiating or maintaining life-sustaining treatments. Decision of withdrawing and withholding treatment has long been practiced by neonatologists, adult and pediatricians intensivists. In this regard, the recommendations of societies encourage medical teams to assess their practices to improve them. Our evaluation is based on the document of the Ethics Committee of SRLF edited in 2010. TYPE OF STUDY: We achieved a retrospective evaluation of professional practices of the transcription of our decisions of withdrawing and withholding treatment. PATIENTS AND METHODS: This study included all children (95 patients) who have had a questioning about life-sustaining treatment of ICU between March 2008 and August 2011 in the pediatric intensive care unit of Children's Hospital of Lyon. Our evaluation is based on the document of the Ethics Committee of French Society of intensive care (SRLF) edited in 2010. We collected epidemiological data on children concerned by questioning about the appropriateness of initiating or maintaining LST and an evaluation of the transcription of our procedures for LST in our folders. Evaluation included 40 cases: 20 folders randomly selected prior an information meeting (January 2011) which were compared with 20 cases occurred consecutively after this information. This meeting was intended to remind recommendations of good practice and principal points of the law. The main assessment measure was the improvement of the practices respecting criteria of the document of the Ethics Committee of SRLF modified for pediatric care. MAIN RESULTS: Epidemiological data on procedures are comparable to literature data. Concerning the evaluation of our practices before/after a briefing and highlighted a tendency to the improvement without statistically significance. The transcription of reflection and the arguments of decision of withdrawing and withholding treatment and evaluation of pain was the points who need improvement. Finally, despite the positive developments in the therapeutic use of analgesics and sedatives, pain continues to be undervalued. CONCLUSION: The evaluation of professional practices is recommended to improve the procedures of questioning about life-sustaining treatments have become an area of expertise in intensive care.