Managing osteoporosis in pediatric patients

I remember very clearly the first time osteoporosis reared its ugly head in clinic. I was monitoring a teenage patient with lupus on high doses of steroids to control her kidney disease. She came into clinic complaining of pain in her lower back that was making it difficult for her to sit or stand for long periods of time. X-rays revealed compression fractures of her lumbar vertebrae, despite compliance with calcium and vitamin D supplements. Physical therapy and 6 months of treatment with alendronate have helped, and 2 years on she remains pain free.

Osteoporosis can be a complication of pediatric rheumatologic diseases, just as in the adult world. The risk for osteoporosis is multifactorial. Medications such as steroids can be instrumental in treating disease, but can also put children at increased risk for low bone density.

Rheumatologic disease itself can be associated with osteoporosis, independent of medication use. Childhood lupus has been associated with decreased bone mineral density [1,2]. Lower muscle mass and tone can contribute to osteoporosis in children with dermatomyositis [3]. Both children with juvenile idiopathic arthritis (JIA) and adults with a history of JIA have been shown to have lower bone mineral density [4,5].

In 2017, the American College of Rheumatology published guidelines regarding osteoporosis [6]. The authors recommended that all adults and children receiving glucocorticoids undergo an initial clinical fracture risk assessment within 6 months of initiation of treatment, and that this risk be reassessed every 12 months. This includes evaluation of steroid use, fall risk, nutrition status, signs of hypogonadism, secondary hyperparathyroidism, thyroid disease, family history of hip fracture, testing of muscle strength, and spine tenderness on exam.

Given these risks, it is important for physicians to discuss bone health with children and their families. Staying active, incorporating calcium and vitamin D supplementation, and minimizing exposure to steroids are all important strategies to keep children healthy with strong bones for the future.