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Dual Energy X-Ray Absorptiometry Measurements in Small Subjects: Conditions Affecting Clinical Measurements

Departments of Pediatrics, Obstetrics and Gynecology, University of Tennessee, Memphis, TN (W.W.K.K., M.H.)
Department of Pediatrics, Obstetrics and Gynecology (W.W.K.K., M.H.), Wayne State University, Detroit, MI
Computing and Information Technology (E.M.H.), Wayne State University, Detroit, MI

Address correspondence to: Dr. Winston Koo, Hutzel Hospital, Department of Pediatrics, 4707 St. Antoine Blvd, Detroit MI 48201. E-mail: wkoo{at}wayne.edu

	ABSTRACT

TOP ABSTRACT INTRODUCTION METHODS AND SUBJECTS RESULTS CONCLUSION REFERENCES

 
Objective: To document the clinical and experimental situations that may affect DXA measurements in small subjects.

Methods: 49 piglets (886g to 21100g) had measurements with either of two pencil beam densitometers (QDR 1000W and QDR 2000 Plus, Hologic Inc, Waltham, MA) using commercial infant (IWB) and adult whole body (AWB) software v5.71p and v5.71 respectively. AWB scans were analyzed with three additional software versions. 35 infants (2115 to 11564g) had IWB measurements.

Results: DXA measurements of total weight, bone mineral content, bone area, bone mineral density, fat and lean mass from IWB scans (all piglets) and from AWB scans (piglets >12 kg) were highly reproducible (p < 0.001). A statistically significant change occurred in at least one of the DXA measurements from the use of different platforms, variations in the amount and placement of covering (e.g., blanket), placement of the external calibration standard, presence of radiographic contrast material, presence of movement artifact, delivery of an intravenous fluid bolus prior to scanning or improper delineation of external calibration standard during analysis. Additionally, results varied amongst different versions of software as well as between IWB and AWB softwares.

Conclusion: In small subjects, consistency in the DXA techniques is paramount for valid and meaningful comparison of DXA data in bone mass and body composition.

Key words: pig, infant, bone, fat, lean tissue, body composition, ash, calcium

	INTRODUCTION

TOP ABSTRACT INTRODUCTION METHODS AND SUBJECTS RESULTS CONCLUSION REFERENCES

 
Dual energy X-ray absorptiometry (DXA) is generally accepted as a noninvasive method to assess bone mass and body composition of small subjects, and there is an extensive body of literature on human studies during infancy [1–16]. However, discrepancies exist in the DXA measured bone mass and body composition among studies, and these may be as high as 18% for bone mass, 15% for fat mass and 8% for lean tissue mass for healthy infants. We have previously documented several practical issues associated with DXA scan acquisition and scan analysis that may lead to spurious results for bone mass measurements [17], but it is not known whether differences in techniques of DXA measurements may be responsible for differences in DXA measured soft tissue composition. This study aims to document practical situations that may affect DXA measurements of soft tissue composition and additional technical issues that may affect all DXA measurements in small subjects.

	METHODS AND SUBJECTS

TOP ABSTRACT INTRODUCTION METHODS AND SUBJECTS RESULTS CONCLUSION REFERENCES

 
DXA Scan Procedures
All measurements were performed using two whole body densitometer (QDR 1000W and QDR 2000 plus) made by the same manufacturer (Hologic Inc., Waltham, MA, USA) and operated in the pencil beam mode. The reference scans were obtained with the subject and the rectangular external calibration standard (step phantom) placed on top of a cotton blanket. The latter was laid over a two-platform system consisting of a manufacturer-provided foam covered rigid aluminum platform which in turn was placed on top of another cloth covered foam pad, the "table pad." Unless otherwise stated, all piglets were scanned in the prone position lying at the center parallel to the long axis of the platform with the head about 2cm from the short axis of the platform. For infants less than three months of age, each subject was swaddled in a cotton blanket during scanning but without additional clothing. A diaper was also used for older subjects. Each subject and any covering or accessories that were included in the scan were weighed separately with an electronic scale. Study weight included the body weight and any articles that covered the subject. During scan acquisition, the external calibration standard was positioned besides (but not touching) the piglet or infant at a level below the head of the subject. For piglet studies, any modifications to the techniques in scan acquisition or scan analysis as part of this study are stated where appropriate. The scans using adult software were performed on the piglets only.

All scans were acquired and analyzed with the commercial infant whole body (IWB) software version v5.64p for the QDR 1000W and v5.71p for the QDR 2000 plus. Both versions of the software were based on validation studies using piglets [18–20]. One series of scans was performed with the QDR 2000 using a commercial adult whole body (AWB) software v5.71 although the scans were analyzed with several versions of AWB (enhanced whole body versions v5.71 and v5.73, whole body version v5.73, and whole body tissue phantom analysis v5.73) from the same manufacturer. As recommended by the manufacturer, the AWB scans were performed with the use of foam table pad only. Other details of scan acquisition and analysis were the same as that for IWB scan.

Animal Studies
Commercial domestic swine piglets were studied to determine the influence on DXA measurements from variations in data acquisition and/or scan analysis that may be encountered during clinical and experimental conditions. The first series of studies performed on the QDR 1000 instrument were designed to test the effect on DXA measurements from variations during scan acquisition, specifically the type of platform used, the effect of blanket and diaper, and "accessories" that may be present in young infants undergoing the DXA study. The "accessories" included a combination of one rubber pacifier, two intravenous catheters each attached to minivolume extension tubing with a T connector and luer lock adaptor, one plastic umbilical clamp, two plastic identification bands, and one adhesive strip bandage. In addition, certain conditions were varied to test the effect on DXA measurements. These included various combinations of two or four layers of blanket above or below the external calibration standard, the completeness of the external calibration standard within the scan field as seen on the video monitor to mimic the situation when a portion of it was inadvertently left out of the scan field, and the presence of radiographic contrast material (barium, iothalamate and iohexol) in amounts that are usually used during clinical studies [21]. DXA data from freshly killed piglets were compared with DXA values from the same piglets after they had been frozen for two to twelve days, thus mimicking some experimental situations. The second series of studies were performed on the QDR 2000 plus instrument and were designed to test the effect on DXA measurements from intravenous or gavage feeding. In addition, to determine the best weight for transition from infant to adult software, we used the commercial adult whole body software for scan acquisition followed by analysis with four different versions of commercial software as described above.

All piglets were studied as part of comprehensive protocols on various aspects of body composition measurement although the number of piglets studied varied depending on the specific aspect studied. Each protocol was approved by the respective Institutional Review Board for animal investigations at the University of Tennessee, Memphis, TN, and Wayne State University, Detroit, MI.

Infant Studies
Infant studies were used to determine the effect of subject movement during data acquisition and variations in the operator dependent delineation of the external calibration standard during scan analysis. The effect of subject movement was determined if an infant had one technically satisfactory scan and one with movement artifact [17]. Manual delineation of the external calibration standard by the operator during scan analysis was performed to mimic the situation when the software dependent automatic delineation had failed. The scans were obtained from a review of scans from infants who participated in various clinical protocols approved by the Institutional Review Board of the University of Tennessee, Memphis, TN. Written informed consent was obtained from the parent of each child.

Statistical Analysis
The equivalence of the multiple DXA measurements in the piglets was determined by paired t test or repeated measures analysis of variance followed by Helmert contrasts, depending on whether the scans were performed in duplicate or triplicate. The precision for each DXA parameter measured was determined with the method of Gluer [22].

The average DXA measurements were used for all other analysis whenever multiple scans were performed under the same condition. The relationships among DXA measured parameters including total weight, fat mass, lean mass, bone area, bone mineral content and bone mineral density under various situations were determined by correlation, t test or repeated measures analysis of variance. The latter was used if the study design required more than two set of scans. Whenever possible, DXA values based on the standard technique of scan acquisition and scan analysis as described above was used as a reference in the simple contrast. The Helmert contrast was used in other comparisons. The ability for AWB to predict IWB measurements for larger piglets was determined by regression analysis.

Unless otherwise stated, all values are mean +/– SD. All statistical tests were performed with SPSS 11.5 for Windows (SPSS Inc., Chicago, IL) at an adopted significance level of 0.05.

	RESULTS

TOP ABSTRACT INTRODUCTION METHODS AND SUBJECTS RESULTS CONCLUSION REFERENCES

 
For the QDR 1000 Instrument
Animal studies.
There were 361 scans performed on 22 piglets. Triplicate measurements obtained as described for reference scans are shown in Table 1. The precision error for triplicate measurements of piglets with average weight of 2794g (range 886 to 8494g) were 0.1, 3.0, 1.5, 2.2, 7.7 and 0.6% for total weight, bone mineral content, bone area, bone mineral density, fat and lean mass respectively.

Infant studies.
For this study, scans from 35 infants with study weights between 1954 and 11564g and ages between 10h to 365d were studied. 29 pairs of scans (one scan with and another scan without motion artifact) were available for determination of the effect of motion artifact and 9 scans were reanalyzed with various operator adjustments of the delineation of the external calibration standard. Consistent with the report of increased DXA bone measurements [17] from motion artifact, the total, fat and lean mass measurements also were increased (p 0.05 for all comparisons). Exclusion of a portion of the external calibration standard significantly affected multiple parameters of DXA measurements (Table 4).

All versions of AWB software had difficulties with analysis of scans from piglets <10 kg, in particular, the bone measurements were extremely low or nonsensical. The whole body tissue phantom analysis software detected only lean tissue mass and reported it exactly as the total weight for all piglets studied. For one piglet with a study weight of 11,255g, each of the two enhanced AWB software reported no body fat in one of the duplicate scans, while the "non-enhanced" AWB v5.73 reported about 250% difference in fat mass between the duplicate scans.

DXA measurements for piglets with weights >12 kg using the IWB and AWB scans are shown in Table 6. When only piglets with weights >12 kg were considered, the precision error from duplicate AWB scans for total weight, bone mineral content, bone area, bone mineral density, fat and lean mass were similar for the two enhanced and one non-enhanced AWB software versions, and none were greater than 0.5, 2.2, 3.3, 1.0, 10.9 and 0.8% respectively. Except for fat mass measurements, each of the three AWB softwares was able to predict the corresponding DXA measurement from the IWB software (Table 7).

	DISCUSSION

The strengths of this study include the most comprehensive determination to date on the various situations that could be encountered clinically and experimentally which may affect DXA measurements in small subjects. The piglet model allows systematic study of technical issues of DXA studies in a far more comprehensive fashion than the use of clinical data alone. The use of different instruments operated in the same DXA technique, namely the pencil beam mode, allows the generalization of our data for the most frequently reported means of DXA investigation in infants and young children.

Many situations involving the DXA system can affect its measurements. It is well known that the earlier prototype IWB software and scan acquisition on the pencil beam DXA without the aluminum infant platform were unsuitable for the study of small subjects [23,24]. In contrast, the current IWB software version v5.64p or later has been validated independently by multiple investigators using the piglet model with the additional use of an aluminum platform during scan acquisition and further modification of the software algorithm for scan analysis [18–20]. The excellent precision of DXA measurement demonstrated in this study is consistent with previous reports [5,7–9,18–20] and is well suited for growing humans and animals with rapidly changing body composition [25,26].

Another situation involving DXA system that critically affects DXA measurements is the use of different types of platform. Aluminum infant platform was used to improve system linearity during scan acquisition and to allow for lowering the detection threshold for bone [18]. It is therefore theoretically possible that the presence or absence of the aluminum platform may contribute to difference in bone mass measurements although our data indicated that there is little or no effect of aluminum platform on bone mass measurements. Presumably the modifications to the algorithm for scan analysis in the current IWB software may have minimized any potential effect on bone measurements from different platforms. However, our piglet model demonstrated that variation in the platform used during scan acquisition, regardless whether it is aluminum or foam material, can result in differences in DXA measured fat mass by as much as 40% for fat mass and by 5% for lean mass.

Operator related issues can affect the function of the DXA system. Thus the placement of the external calibration standard during scan acquisition and or its delineation during scan analysis potentially can significantly affect all DXA measurements. During any clinical study, it is possible that one or more blankets used to cover the infant may be extended to cover the external calibration standard. Alternately, several layers of blankets may be placed above the rigid aluminum platform but under the external calibration standard for the comfort of the infant undergoing a DXA study. The placement of blankets is directly controlled by the operator, and our data demonstrated this is another operator related issue that can affect DXA measured total weight, lean mass and bone mineral density.

Subject related issues can affect the DXA system and thus the DXA measurements. Covering the infant is essential to avoid any stress to the maintenance of body temperature, and our data show that the usual covering with blanket and diaper can affect both the DXA measured total weight and results in an increase in soft tissue mass, specifically lean body mass. It seems reasonable to speculate that similar material to the cotton blankets, for example cotton underwear or clothing, could have a similar effect on DXA measurement. Based on the additional data from the "accessories" present during DXA studies, it is theoretically possible that any non-metallic covering could increase the DXA total weight and lean mass. It is important to keep in mind that the greater the amount of covering (blanket or clothing etc.) related to the infant’s weight, results in a greater change in DXA measured body composition. Furthermore, the same blanket used for a small infant would result in proportionately greater change in DXA-measured body composition compared to its use in a larger infant. The resultant differences may invalidate some of the conclusions if body composition measurement is one of the outcome variables. Thus it is critical for consistency in and accurate documentation of the type, amount and weight of covering used for each subject to maintain the validity of any DXA measurement.

In clinical studies, artifacts from spontaneous movement of the subject has been reported to affect DXA bone mass measurements [17], and it is not surprising that the current data demonstrated that movement can affect soft tissue measurements. The effect of intravenous or enteral feeding on DXA measurements is not known. Our data demonstrated that within 30 minutes after an intravenous bolus of parenteral nutrition solution, both the DXA total and lean mass are significantly increased although it seems unlikely that a subject receiving routine parenteral nutrition therapy with an intravenous infusion rate of <20% of the bolus infusion used in this study would have significant effect on the DXA measurements. This is consistent with the lack of any effect on DXA measurements at a somewhat longer interval after gavage feeding of milk.

Our data extended the previous observation that radiographic contrast material could have variable effect on bone mass measurements [17] to include DXA total weight and lean mass. Thus, for infants that may be subjected to other radiographic investigations, it seems prudent to schedule DXA studies prior to the contrast studies.

It is not surprising that supine or prone position or freezing the piglet carcass did not affect DXA measurements. This knowledge provided assurance that the clinical situation of having the infant positioned in a posture of comfort or the experimental situation when a period of freezing is needed before DXA measurement will maintain the validity of these measurements, although we did not determine whether the same relationship existed if the piglets had been completely thawed prior to repeat scanning.

The lack of detail on the techniques employed in many published DXA studies contributed to the difficulty in understanding the discrepant results in clinical studies. The inability to convert the scans generated without the aluminum platform to those generated with the aluminum platform for direct comparison have resulted in multiple reports that used a combination of techniques that can affect DXA measurements. These include the use of earlier IWB software [3,10], the lack of documentation of the use of aluminum platform [11–13], the use of an additional foam pad without specific documentation whether the aluminum platform was used [4,7,14] and the need to combine the data generated with older and current versions of IWB software because of the longitudinal study design [9,15,16].

Our data clearly demonstrated that it would be impossible to document every conceivable scenario that may affect DXA measurements, and the onus on the investigators is to follow the standardized techniques reported here and in the validation studies [18–20] and be cognizant that even seemingly routine procedures such as adding a blanket and diaper can potentially affect DXA measurements. It is therefore critical that, for measurements using any DXA system, the investigators must document the exact procedures used during scan acquisition and scan analysis and to maintain consistent procedures for all studies to minimize any spurious data and allow comparison of data within and among studies.

As the infant grows, it is important to determine the optimal weight or size to transition to the validated DXA AWB software for large subjects. Our data clearly demonstrated that there are no significant differences between the two versions of enhanced AWB software, but these versions differed significantly from the "non-enhanced" AWB software. Our data indicated that a change in version number of the software does not necessarily mean there are significant differences in the DXA measurements. Thus the onus on the manufacturer is to provide easily accessible documentation for the details on any change, if any, with each change in the software version for the DXA instrument.

Other than for fat mass measurement, these three AWB softwares showed statistically significant prediction for the IWB measurements. However, the predictive ability for only the DXA measured total weight and lean tissue are likely to be of sufficient level for the AWB software to be used in subjects of similar weight to older infants. In any case, none of the DXA measurements obtained with AWB is directly interchangeable with those obtained from IWB, and a conversion factor is needed. The whole body tissue phantom analysis v5.73 was useless for small subjects.

	CONCLUSION

TOP ABSTRACT INTRODUCTION METHODS AND SUBJECTS RESULTS CONCLUSION REFERENCES

 
Multiple technical issues can critically affect DXA measurements in small subjects. An understanding of these issues is crucial to the interpretation of the current literature and ongoing longitudinal studies. To minimize any misinterpretation of the data and to maintain the validity of DXA measurements in infants, the onus for the investigators is to provide details of all steps in the scan acquisition and analysis and maintain consistency in these procedures. The onus for the manufacturer is to provide details on the exact modifications, if any, whenever there is an "upgrade" in the software release rather than just a cosmetic change in the version number for marketing purposes. Further studies are also needed to determine the best means for the transition in DXA techniques as the infant grows.

Received June 26, 2003. Accepted October 29, 2003.

	REFERENCES

TOP ABSTRACT INTRODUCTION METHODS AND SUBJECTS RESULTS CONCLUSION REFERENCES

 

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This Article Abstract Full Text (PDF) Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Koo, W. W. K. Articles by Hammami, M. Search for Related Content PubMed PubMed Citation Articles by Koo, W. W. K. Articles by Hammami, M.