by Joyce Clay
Osteoporosis or brittle bones can plague the very young or the very old. Characterized by fragility, or brittleness, the bone is less dense and therefore prone to breaking. Typically, one thinks of a frail, elderly woman or man with minimal fat as the person most likely to be diagnosed with osteoporosis. However, an infant or a child, preteen, or adolescent can also have issues with this disease, and its prevalence is especially high in children with complex medical issues.
One needs to differentiate the terms osteoporosis and osteopenia. You can think of bone density as a spectrum, with mild or moderately low bone density categorized as osteopenia, and very low bone density diagnosed as osteoporosis. Children or adults with osteopenia have a greater risk than the average person of the same age of developing fractures. Osteoporosis occurs when bone density is greatly reduced, and commonly leads to fractures.
Causes of Bone Density Problems
Younger persons tend to develop osteopenia because of a variety of issues. Some have had cancer, and the life-saving chemotherapy they were given predisposes the child to this potential complication. Others are asthmatic and the necessary steroids needed to allow breathing can cause osteopenia. The use of antiseizure medications such as Dilantin or Depakote is cited in literature as increasing the risk for brittle bones. Other medications, such as Neurontin for neuropathies or Protonix for gastrointestinal reflux, may also contribute.
Children who are not mobile or cannot bear weight in a standing position also are at increased risk of osteopenia and osteoporosis. Bone density increases with weight-bearing and exercise, and many children with disorders such as cerebral palsy are unable to bear weight enough to build bone.
Nutritional status can also contribute to osteoporosis and osteopenia. Children on IV nutrition (TPN) often develop osteopenia or osteoporosis. Children who are malnourished may also not build bone appropriately. Certain other conditions, including kidney and thyroid diseases, as well as prematurity, can also lead to decreased bone density.
The young baby who has a history of multiple fractures may have a genetic disease commonly classified as Osteogenesis Imperfecta. Infants and children with these diseases have a different cause for their brittle bones, but also develop osteopenia or osteoporosis. Some have bones so brittle that they can break a long bone such as the femur just by moving their legs in bed while they sleep.
Diagnosis and Treatment
Diagnosis of orthopedic issues includes diagnostic labs such as Vitamin D and Calcium levels, Dexa scans, and X-rays. A Dexa scan is a special X-ray that measures the density of bone by determining the amount of high and low energy X-ray beams that pass through bone, usually in the hip or spine.
The child suspected of having osteopenia or osteoporosis should be referred to a specialist for evaluation and treatment. An endocrinologist, nephrologist, or orthopedic specialist may treat children with osteopenia or osteoporosis.
Treatment options include the encouraging of exercise, such as the inclusion of resistance training. Swimming can improve aerobic capacity and has the additional component of resistance. Children who are not mobile may be encouraged to use a stander or gait trainer to develop more bone. There is also some evidence that standing on a vibrating mat or using a vibratory vest may help to increase bone density in this population.
Nutritional therapy consists of increasing vitamin D and calcium, as well as maximizing the child’s nutritional status. The amounts recommended depend on the child’s nutritional status and current labs.
Some children with a history of long bone or compression fractures may require more intensive treatment. These children typically have a poor Dexa scan score, and repeat scans will show progressive loss of bone. Some of these children will be treated with Bisphosphonates, which are given intravenously one to four times a year. However, the use of bisphosphonates is controversial, due to severe side effects in some children, and a lack of clinical evidence, especially in children with neuromuscular disorders. In addition, a child needs to be fracture free at the time of infusion, which can be difficult for children who may break a bone just by walking.
In summary, one would think that osteopenia and osteoporosis only occur in the older population. However, this condition can afflict children as well, especially those with complex medical issues. Encouraging bone health is a necessity for everyone, beginning with infant nutrition and continuing throughout life.