Pediatrics: Bone Density Basics

Osteoporosis can reduce to ___% with a ___% increase in peak bone mass

50% with a 10%

True or false, DXA should be the only data used to diagnosis of osteoporosis

False

6 other assessments that should be made to diagnose a pediatric patient for osteoporosis

Family hx, relevant lab studies, urinalysis test, xray exams, bone-age measurements, and skeletal survey results

DXA should be considered in pediatrics in what 3 cases?

Primary bone disease, secondary disease that affect bone, and when assessing treatment and intervention

Scanning patients younger than ___ is discouraged

5 years old

Why is scanning patients younger than 5 discouraged?

Sedation risks outweigh the benefits

What two body parts for scanning is not useful in young children, explain why

Forearm and Femur, lacking database information and reproducibility issues

Scans for child 0-5 years old should assess which area?

Lumbar spine

Whole body scans of children ___ and older provide accurate BMC and Area BMD

3

Term for bone formation

osteogenesis

A complex process that converts connective tissue into bone

osteogenesis

Ossification bone development where bone is laid over connective tissue

Intramembranous Ossification

Ossification bone development where bone is built over existing cartilage

Endochondral Ossification

A cavity is created in the bone to do what?

Host Bone Marrow

A cavity created in the bone is done by which cells?

Osteoclasts

Bone growth begins after when?

Conception

Bone growth continues to strengthen until what is reached?

Peak Bone Mass

Peak Bone mass is typically achieved by ages ___ to ___, 90% attained by age ___.

25-30, 20

Peak Bone mass is typically higher in _____

men

List 8 disorders affecting pediatric bone growth that would indicate a DXA scan

Osteogenesis imperfecta, idiopathic juvenile osteoporosis, genetic defects, endocrine disorders, chronic diseases, nutritional disorders, pubertal growth delays, and medications.

Lung disease that doesn’t affect bone health directly but the treatment with glucocorticoid can cause bone loss

Asthma

How does treatment with glucocorticoids for asthma affect bone health for pediatrics?

Decreases the absorption of calcium

What daily dose of steroids for pediatrics can cause bone loss?

7.5mg daily

Most bone loss for pediatric patients who are on steroids experience the most bone loss when?

within their first year of taking steroids

Wilson’s disease and Cholestatic Liver disease are a ___ cause of osteoporosis

secondary

Pediatric patient’s with liver diseases have up to a ___% chance of having a fracture

40%

Liver disease where the body doesn’t discharge adequate copper into bile for excretion, so there is an increase of copper and iron in the body which affects calcium absorption

Wilson’s Disease

Liver Disease where the body builds up bilirubin which can hinder osteoblast function

Cholestatic liver disease

Chronic liver disease´s in pediatric patients can be treated with what?

Calcium, vitamin D, and Bisphosphonate Use

Disease in pediatrics that inhibits hydroxylation of vitamin D

Chronic Kidney Disease

Disease in pediatrics that causes increased reabsorption rates higher than bone formation rates

Secondary Hyperparathyroidism

Treatment for CKD in pediatrics involves what?

Vitamin D supplementation beginning around Stage 3 CKD.

Genetic pediatric disorder causing mucus buildup in the lungs, pancreas, and other organs

Cystic Fibrosis

What are two common fractures associated with cystic fibrosis

rib fractures and vertebral fractures

Bone demineralization can be seen as early as age ___ in children with cystic fibrosis

5

Every ___ to ___ years for pediatrics with cystic fibrosis shows a loss of ___ SD in BMD

6-8 years, 1 SD

What are the two reasons for bone loss in pediatrics with cystic fibrosis

malnutrition with malabsorption of vitamins D and K and steroid treatments

Is treatment for cystic fibrosis pediatric patients with bone loss recommended?

Often contraindicated, more focused on preventative with increased activity, increased sunlight exposure, and maintain healthy nutrition

Pediatric disease where bones become soft and weak for deficiencies in Vitamin D, phosphates, and calcium

Rickets

Rickets develop in children with what?

poor nutritional habits and conditions that cause malabsorption.

What is the treatment for Rickets?

Vitamin D and calcium

Autoimmune disease caused by a lack of insulin production in the pancreas, causing spikes in blood glucose level

Type 1 Diabetes

Diabetes is linked to ____ bone mass in pediatrics

low

Insulin resistance in the body

Type 2 diabetes

What gland controls growth hormone?

Pituitary Gland

Endocrine disorders in pediatrics affect bone growth how?

Bone absorption rates stay the same but bone formation is decreased.

In pediatric patients with endocrine disorders, what therapy can raise BMD?

Growth Hormone Therapy

How do eating disorders increase the risk of low bone mass?

Low BMI, malnutrition, decreased estrogen or amenorrhea in girls, growth stunt in boys

What populations are affected by Female Athlete triad syndrome?

Runners, gymnasts, dancers, and figure skaters

What is the treatment for female athlete triad syndrome?

Vitamin D, calcium, hormone replacement, bisphosphonates, lifestyle changes, counseling, and increasing weight

Disorder that influences bone mass and bone metabolism through absorption of calcium, vitamin D, and other nutrients

Gastrointestinal disorders

Immune disorder that destroys the lining of the GI tract when gluten is consumed

Celiac Disease

What fraction of pediatric patients with inflammatory bowel disease have ulcerative colitis or Crohn’s disease?

1/4

What is the treatment for celiac disease and what is the treatment for inflammatory bowel disease?

Celiac treatment is to go gluten free, inflammatory disease treatment is glucocorticoids, further decreasing bone mass.

Cancer is diagnosed in ____ children everyday

40

Survival rates for child cancer has increased to ____ percent

90%

How does muscular dystrophy and spina bifida affect BMD?

Reduces movement and mobility which causes an increase in absorption rates and a decrease in bone formation

What is the treatment for pediatric patients with neuromuscular diseases?

Weight bearing physical activity

Children are routinely prescribed what medication for neuromuscular diseases?

Anticonvulsants

Organ transplantation in pediatrics can prevent a patient from reaching what?

Peak Bone Mass

Pediatric patients awaiting organ transplant are already at risk of osteoporosis from what 3 things?

Malnutrition, reduced mobility, glucocorticoid use

Post transplant in pediatrics, what are three examples of immune suppression drugs?

Tacrolimus FK506, Cyclosporin A, Sirolimus

What transplants types receive higher doses of daily prednisone?

Liver and Heart

Daily Prednisone post transplant can vary from what dose?

2.5mg-7.5mg

Autoimmune disorder that causes an inflammatory response seen in joints, bones, muscles, eyes, skin, and intestinal tract

Juvenile arthritis

Common rheumatic disease that causes a rash on the skin/knuckles and causes weakness in muscles

juvenile dermatomyositis

Common rheumatic disease that affects the joints, skin, kidneys, and blood

Juvenile Lupus

Common Rheumatic disease that causes stiffness, sleep disruptions, exhaustion, and aches most commonly in females and diagnosed before puberty

Fibromyalgia

Low bone mass was found in what percent range of cases for rheumatic disease in pediatrics?

38-70%

Fracture rates are as high as what percent for rheumatic diseases in pediatric patients?

25%

Low bone mass in rheumatic diseases was exacerbated by what treatment?

Glucocorticoids

Seizures or epilepsy can cause increased low bone mass due to what?

Less activity and ketogenic diets

Treatment for seizures can reduce bone mass, list 4 medications

1) Phenytoin

2) Phenobarbital

3) Primidone

4) Valproic Acid

Antiepileptic drugs can increase pathological fracture is by x____

x6

Why do antiepileptic drugs increase fracture risk?

Cause low bone density, increase fall risk, and increase aggressive convulsions

Hereditary disorder related to abnormal hemoglobin

Sickle Cell Disease

List 3 acute conditions of sickle cell disease

vaso- occlusive crisis, infections, and osteomyelitis

List 4 chronic conditions of sickle cell disease

osteoporosis, osteonecrosis, arthritis, and impaired growth

Pediatric patients with sickle cells disease are ____ percent lower BMD across all scanning regions compared to normal

21%

Common findings in pediatric patients with sickle cell anemia

Fracture or collapsed vertebrae and vitamin D deficiency

Pediatric disorder developed from increased production of cortisol hormone

Cusing’s syndrome

Cortisol hormone is produced by what glands in response to ACTH stimulation

adrenal

Cushing’s syndrome is common or rare?

Rare, only 2-5 new cases per million people each year.

Cushing’s Syndrome is common in children over what age?

7 years old

What tumors are common in toddlers and infants in relation to cushing’s syndrome?

Adrenal tumors

Cushing’s syndrome causes ____ failure, and delays in what?

growth failure, and delays in onset of puberty

Cushings syndrome affects peak bone mass and decreases ____ formation

osteoblasts

Another term for Cushing’s Syndrome is what?

Hypercortisolism

Cushing’s syndrome is treated with glucocorticoids which increased ____ rates in children

fracture

What is Klinefelter’s Syndrome?

Males born with an extra X chromosome

Klinefelter syndrome bone density is normal in males until when?

They hit puberty

Klinefelter Syndrome results in what 3 things in males?

Small Testicles, delayed puberty, and low levels of testosterone

Klinefelter syndrome causes hypo______

gonadism

Klinefelter syndrome depresses ___ formation, and increases ____ resorption rates.

osteoblast formation, bone resorption

Syndrome that is rare, affecting females who are born without one or part of one X chromosome

Turner Syndrome

Only ____% of pregnancies reach full term for Turner’s syndrome

1%

Turner Syndrome is responsible for __ % of miscarriages with in the first trimester

10%

Girls born with turner syndrome have ___ deficiencies and are treated with what?

Estrogen, growth hormone therapy and estrogen replacement therapy.

Another term for Brittle Bone Disease

Osteogenesis Imperfecta

The most common form of Osteogenesis Imperfecta is which type?

Type 1