OSTEOPOROSIS IN CHILDREN

AND ADOLESCENTS
Hisham Abdel-Ghani
MD Orthopaedics
Cairo University
www.pediatricorthopaedics.com
DEF.
a systemic skeletal disorder characterised by low
bone mass and micro-architectural
deterioration of bone tissue, with a
consequent increase in bone fragility and
susceptibility to fracture
 Osteopenia in children

• Mineralization defect (rachitic)

• Osteoporosis
• Others
 Increasing diagnosis
• improved care provided to children with
chronic illness
• The availability of methods to assess bone
density in children
• possibility of medical treatment has also
resulted in an increased awareness of
osteoporosis
 Etiology
Primary intrinsic bone abnormality
• Osteogenesis imperfecta
(OI)
• Idiopathic juvenile
osteoporosis ( IJO)
• Osteoporosis
pseudoglioma syndrome
Secondary
• Reduced mobility
• Inflamatory cytokines
• Systemic glucosteroids
• Disordered puberty
• Poor nutrition/low body
weight
Secondary OP
REDUCED MOBILITY

• Cerebral palsy
• Spinal cord injury and spina bifida
• Duchenne muscular dystrophy
• Spinal muscle atrophy
• Head injury
• Unknown neurodisability
Inflammatory cytokines

• Juvenile idiopathic arthritis

• Systemic lupus erythematosis
• Dermatomyositis
• Inflammatory bowel disease
 Systemic glucocorticoids
• Rheumatological conditions
• Inflammatory bowel disease
• Nephrotic syndrome
• Duchenne muscular dystrophy
• Cystic fibrosis
• Leukaemia
• Organ and bone marrow transplantation
 Disordered puberty
• Thalassaemia major
• Anorexia nervosa
• Gonadal damage due to
radiotherapy/chemotherapy
• Klinefelter syndrome
• Galactosaemia
 Poor nutrition/low body weight

• Anorexia nervosa
• Chronic systemic disease
• Inflammatory bowel disease
• Cystic fibrosis
• Malignancy
• Mostly secondary
– Endocrine
– Connective tissue
– GIT
– Drugs, steroids, anticoagulants
– Immobilization
• Primary (rare)
Osteogenesis Imperfecta OI
Osteogenesis Imperfecta OI
Osteogenesis Imperfecta OI
Osteogenesis Imperfecta OI
Juvenile idiopathic osteoporosis
IJO
• Etiology
• 5 – 17 ys
• Self limited sudden bone loss
• Active process of bone formation preceded by
active bone resorption
• Osteoblast respond to active vit D
• Normal or low PTH
• Normal ca, increase p, normal urine excretion of p
• Normal or increased hydroxyproline excretion
C/P
• Bone and joint pains, knees, tibias, metatarsi,
back pain
• Gait abnormalities, muscle weakness,
decreased physical fitness
• Fractures, thoracic and lumbar vertebrae, long
bone metaphyses
•  deformation of the skeleton, short stature
Diagnosis
• BMD > 2 SD below normal for age and sex (Z-
score < 2)
• Compression # spine (no schmorl nodules,
deformation of single vertebara, bone atrophy

• Increased Alkanline phosphatase

Diagnosis
• Exclusion of other causes of 2ry OP
• Rheumatic disordrs
• GIT
• Chronic liver disease (labs)
• Chronic renal disease (labs)
• Drug intake
• Abd U/S
• PTH level
• T3, T4
• OI (increased, Procollagen type I)
• 1ry hypoparathyroidism (low ca
TTT

• .5 to 2 ys
• Ca rich diet
• Ca, vit D,
• Calcitonin
 Prognosis
• Most children with IJO experience a complete
recovery of bone tissue. Although growth may
be somewhat impaired during the acute phase
of the disorder, normal growth resumes – and
catch-up growth often occurs – afterward.
Unfortunately, in some cases, IJO can result in
permanent disability such as curvature of the
upper spine (kyphoscoliosis) or a collapse of
the rib cage
 Failure to achieve PBM
• Over the past 3 decades, there has been an
increase in the incidence of fractures in
children
• 63% of 5-17 y.o. not active enough for optimal
growth
• Adolescents less active than children 2-12
years old (33% vs 43%)
• Decline in activity with age and gender (girls at
14-15 yrs vs boys 16-17 yrs)
• Girls less active than boys: 30% vs 50% at 5-12
yrs vs 25% vs 40% at 13-17 yrs
• Girls - less intense physical activities
 Effects of inactivity

– Childhood obesity
– Type 2 diabetes
– Hypertension
– Osteoporosis
– Depression
– Smoking/alcohol/drugs
– Adolescent pregnancy
• TV, computer, Nintendo
• Inactive parents
• Inadequate access to quality physical
education classes
• Lack of recreational facilities
 BMD measurement

• DXA
• BMD (g/cm2)= BMC / surface area
• T-score: compare the pt. BMC to healthy young adults = number of (SDs)
away from the healthy population mean BMD
• epidemiological studies have confirmed an association
between measurements of BMD and fracture risk in the
adult population
• (WHO) classification defines osteoporosis as a T-score of
2.5 or Below and osteopenia as aT-scorebetween1and2.5
 Acquisition of peak bone mass
• The rate of bone mass acquisition tends to
mirror height velocity and is greatest during
puberty. Bone mass continues to accumulate
until the late teens, early twenties, at which
time peak bone mass (PBM) is achieved
• Women tend to reach PBM sooner than men
and blacks sooner than whites [7–9]. On
average,90% of PBM is acquired by the age of
19 years
 BMD in pediatrics
• WHO criteria for diagnosing osteoporosis in
adults should not be applied to children
• The use of T-scores is not applicable because
children have not yet reached PBM
• Instead, a child’s BMD must be converted to a Z-
score by comparison to pediatric normative
data. The term ‘low bone density for
chronologic age’ should be used if the Z-score is
below -2.0 SD
Can measurement of BMD be
used to predict fracture risk
in children and adolescents?
 Diagnosis of OP in pediatrics
• presence of both a clinically significant
fracture history
• one fracture of the long bones in the lower extremities,
vertebral compression fractures, or two or more long-
bone fractures of the upper extremities

• and low bone mass

 Bone Health for Children

• Use age-appropriate teaching tools

• Encourage healthy bone building habits:
• Calcium
• Vitamin D

• Supplemented for exclusively breastfed

• Serve fortified foods
• Encourage regular exercise
 Bone Health for Adolescents

• At risk due to rapid growth

• Calcium (1300 mg)
• 1 hour exercise
• Avoid risky behaviors:
• Eating disorders
• Over-exercising
• Peer influence: smoking, alcohol,
• anabolic steroids
 Goal for Daily Calcium Intake

• Age (years) Calcium (mg)

• 1 to 3 400
• 4 to 8 800
• 9-18 1300
• 19-50 1000
• 51+ 1200
• It may be unhealthy to take more than
2500 mg/day
 Adequate Intake of Vitamin D
(for Healthy Individuals)

• Age (years) Vitamin D (IU per day)

• Birth to 50 200
• 51 to 70 400
• 71+ 600
• (Some individuals require much more)
 Exercise has the potential to:
• Increase bone density in youth and young
• adulthood
• Maintain and may modestly increase bone
density in adulthood
• Prevent and minimize kyphosis
• Increase muscle mass
• Improve balance and agility
• Reduce the risk for fall-related fractures
 Physical Activity

• Weight bearing
– Put stress through the bone
– Impact exercises
• Resistance
– Exercises that cause compression through the
bone as the muscle contracts
• Balance training
 Physical Activity
• Weight bearing
• • Moderate intensity, 30 minutes to 1 hour,
• most days of the week
• • Resistance
• • 8 to 10 exercises, 8 to 12 repetitions, 2 times per
week
• • Balance training
• Tai Chi, specific exercises