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Osteroporosis: Our Kids at Risk

Glenrose Pediatric Rehab Grand Rounds December 2012

Lyn Sonnenberg

on 12 March 2016

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Transcript of Osteroporosis: Our Kids at Risk

Osteoporosis: Our Kids at Risk
1115 Abstracts
38 Potentially
Important Articles
21 Articles Included
9 Bisphosphonate
Intervention Articles
5 Vitamin D & Calcium
Intervention Articles
7 Weight-Bearing/Physical
Intervention Articles
Duplications, review, and
background articles and
those not meeting
inclusion criteria were
Underwent full-text review
Two-stage review, data
abstraction, and classification
of articles
Level B = Probably Effective
Level C = Possibly Effective
Level C = Possibly Effective
Level U = Data Inadequate
Level U = Data Inadequate
Level U = Data Inadequate
Improve BMD
Fracture Rate
Class I
Randomized, controlled clinical trial with masked or objective outcome. Relevant baseline characteristics presented and substantially equivalent among treatment groups or appropriate statistical adjustment for differences. Also require:

A Concealed allocation
B Primary outcome(s) clearly defined
C Exclusion/inclusion criteria defined
D Adequate accounting for drop outs (80% complete trial)
Class II
Prospective matched group cohort study in representative population with masked outcome assessment that meets b-d OR a RCT in a representative population that lacks one criteria a-d.
Class III
All other controlled trials in a representative population (including patients serving as their own controls), where outcome is independently assessed, or independently derived by objective outcome measurement.
Class IV
Studies not meeting Class I, II or III including consensus, expert opinion or a case report.
Level A
Established as effective, ineffective or harmful for the given condition in the specified population. Requires at least two consistent Class I.
Level B
Probably effective, ineffective or harmful for the given condition in the specified population. Requires at least one Class I or at least two consistent Class II.
Level C
Possibly effective, ineffective or harmful for the given condition in the specified population. Requires at least one Class II or two consistent Class III.
Level U
Data inadequate or conflicting; given current knowledge, treatment is unproven.
Systematic Review: Methods
Comprehensive literature search performed
Databases searched: MEDLINE, PubMed, CINAHL, AMED, Cochrane Reviews, EMBASE, EBM Reviews

Inclusion criteria:
English full text articles
≥5 participants receiving intervention
Childhood Physical Disability (CP,DMD,SB, JRA and rheumatologic conditions)
<19 yrs, Bisphosphonates, Vit D, Ca, Weight-bearing)

Exclusion criteria:

Populations excluded: healthy and adult populations
Conditions excluded: e.g. anorexia, inflammatory bowel disease, cystic fibrosis, gestational or neonatal children, malnutrition, transplant patients
Wolff's law is a 19th century theory that states that bone in a healthy person or animal will adapt to the loads it is placed under.

If loading on a particular bone increases, the bone will remodel itself over time to become stronger to resist that sort of loading.
The external cortical portion of the bone becomes thicker as a result.
Weight Bearing: Background
Standing programs are used as part of a postural management approach in children with CP.
Stimulates anti-gravity muscles
Increasing strength and endurance
May be useful in maintaining BMD in children with CP.
Osteogenic signals from the muscles
Loading of the bone due to gravity
Weight Bearing: Background
Children with CP have low bone mineral density (BMD) which leads to ↑risk of fragility fractures

Risk factors for low BMD and fragility fractures include
Decreased weight-bearing
Use of anti-convulsants
Poor nutrition
Decreased exposure to sunlight

Lack of consensus on which strategies to use
Clinicians are faced with many management questions including:
Controversy over when to measure BMD?
How to use this information?
When to incorporate vitamin D, calcium and/or bisphosphonates into prevention or treatment plan?
Prevention & Treatment Strategies:
To conduct a systematic review to inform and develop evidence-based clinical practice guidelines for children with CP and low BMD.

Research Question:
In children with CP and restricted mobility, are the following interventions effective in improving BMD & decreasing fragility fractures:
Objective & Research Question
Literature Search:
Databases searched: MEDLINE, PubMed, CINAHL, AMED, Cochrane Reviews, EMBASE, EBM Reviews
Manual search of all review papers and reference lists
Inclusion Criteria:
English full text articles
≥10 children/youth participants with CP receiving intervention
Data Abstraction & Classification:
In accordance with Clinical Practice Guideline Process Manual of the American Academy of Neurology (AAN)
Each article was reviewed, abstracted and classified twice
Expert panel reviewed and substantiated the classifications and the recommendations
Osteoclasts break down bone cells
Osteoblasts build bone mass
Constant remodelling of bone between the osteoclasts and osteoblasts
Osteopenia occurs when osteoclast activity > osteoblast activity
Osteoclasts have constant turnover, and normally destroy themselves by apoptosis
Bisphosphonates – How do they work?
Henderson RC et al. J of Pediatrics;2002
BMD increased by 89%±21% in tx
group in the LDF region 1 vs
control grp after 18 mo.
BMD increased by 33%±3% in the
LS (p=0.01) vs control group.
3 subjects in control grp had a
fracture during 18-mo study period
Description of Study
Class I
Evidence for improved LDF and LS BMD with pamidronate
Fractures only occurred in control group
RCT of 14 children with quadriplegic CP
(Age 6-16yrs, 13/14 had at least 1 previous fracture)
Tx group: Pamidronate IV (1mg/kg for 3 days every 3 mo for 1 year)
Impact of Bisphosphonates on BMD and Fracture Rate


There is support for including weight-bearing activities into a prevention protocol.
Further details on a specific program still needs to be elucidated through additional research.
Weight Bearing: Clinical Implications
Pediatric Spina Bifida
Review: The Journal of Spinal Cord Medicine
Marreiros et al 2012(35):1 p9-21
11-30% frequency

Etiological Factors
Previous spontaneous fracture
Non-ambulatory status
Higher level of neurological involvement
Higher body fat levels
Post-operative inactivity
Treatment Considerations
Constipation frequent problem
Hypercalciuria secondary to immobilisation
Metabolic calculi exacerbated by Calcium supplement
however restriction not recommended
Practice Points
Fracture risk evaluated at each visit
Replace VitD and Cacium deficiencies
Encourage weight bearing activities
No evidence to recommend BMD
If fragility fracture occurs, there are no guidelines available for further management
Fetal Bone Strength and Umbilical Cord Length
Journal of Perinatology 2009 (29) p603-605
Wright and Chan
Infants with a short umbilical cord have lower tibial bone density (measured by sunlight omnisense) independent of birth weight, gender, cord diameter, maternal age, placental weight.
Thought to be secondary to decreased movement
Autism Spectrum Disorders and Nutrition, Physical Activity and Bone Mineral Density
Journal Developmental & Behavioral Pediatrics
Soden et al 2012 33:618-624
Children 10 - 18 years of age
15% (n=4) had low BMD (>-2SD)
15% (n=4) at risk (>-1SD)
54% insufficient 25-0H VitD
Positive bivariate correlation
Recommended calcium
Recommended calories
Children with Epilepsy
Pediatric Neurology 2010 42:385-393
Shellhaas and Joshi
Kids with CP
Fracture rate similar to that of typical children
Highest in most severely impaired children
Risk Factors
lighter children are often transferred or carried
more exposed to stresses than can cause fractures
Kids with CP
Ambulatory Status
Nutritional State
Extent of Neurological Injury
Degree of Physical Disability
Dietary Intake of Calcium & Vit D
Periods of Immobilization
Order of Importance
Severity of neurological impairment
Increased feeding difficulty
Use of anticonvulsants
Lower triceps skin-fold measurement
Henderson et al J Pediatr 2002
Measuring Bone Mineral Density (BMD)
Single- & Dual-energy X-ray Absorptiometry (DXA)
Quantitative computed tomography (QCT)
Quantitative Ultrasound (QUS)
Radiographic absorptiometry
Most common
Uses less X-radiation
less than one CXR or flight across the country
Cannot distinguish trabecular bone from cortical bone or material properties of bone (other than Calcium)
In Part not the Whole
DXA measures a 2-D area of the bone
Not a true volumetric density
Whole body measurement is the preferred approach, particularly in the growing child
Kids with CP
acquired bone-related pathology or surgical hardware
inability to properly position
severe contractures
artifacts from muscle movement
Alternative DXA Scanning Site
Distal Femur
Sample 3 regions consisting of the different types of bone
Bone strength
Genetic Factors: 50-90%
Normal daily physical activities
Cyclic metabolic fluctuations
Accumulated acquired physiological stressors
Chronic illness
Inflammatory diseases
Neuromuscular diseases
Nutritional compromise
Medications (prescribed or otherwise)
in bone
reduction in
fracture risk
At the end of today’s presentation, the learner will:
1. Identify pediatric patients at risk for osteoporosis
2. Evaluate the literature and recognize its influence on evidence-based practice
3. Facilitate the management for prevention and treatment of osteoporosis according to the clinical practice guidelines presented
Lyn K. Sonnenberg, MD, MSc, BSc(Hon), FRCPC
Neurodevelopmental Pediatrician,
Medical Director, Complex Pediatric Therapies Program
Glenrose Rehabilitation Hospital
Assistant Professor, University of Alberta,
Faculty of Medicine and Dentistry

Are we doing enough?
What are we doing now?
~5% of kids
Kids with 85%ile > BMI <5th%ile
Feeding & Swallowing concerns
Dietician (Tania Vander Meulen, MEd, BSc, RD)
1000mg Calcium
1000IU Vit D
Scoliosis & Spina Bifida
no set guidelines
no set guidelines
Neurology (Anticonvulsants)
Pamphlets to parents & teaching by nursing
Vit D and Calcium reviewed each visit
Written in recommendations & followed up by MD
Who should be doing it?
Community Pediatricians
All of the Above
7 year old girl
Spina Bifida
High Lumbar Lesion
Incontinent bowel and bladder
Likes Justin Bieber
Populations at Risk
Systematic Review of the Evidence
Weight Bearing
What are we doing?
Bisphosphonates encourage osteoclasts to undergo apoptosis
Full transcript