Osteoporosis & Children
Is your child at risk of Osteoporosis?
Most people are shocked to hear that children can be affected by osteoporosis. There are no statistics; however, no child should be left at risk of this silent disease. Anyone under 21 years of age who is at risk can only be scanned on a DXA machine that has the additional software for children and an X-ray of the left hand is necessary to check chronological age with bone age. It is important that parents seek advice and treatment from a specialist who deals with children with bone disorders.
The following are a list of risk factors that can place a child at risk of developing osteoporosis. Some are the secondary effects of a disease and/or the treatment for a disease that can place a child at risk.
- Genetics: Family history, especially if combined with a second risk factor.
- Metabolic disorders: e.g. Homcystinuria
- Osteogenesis imperfecta: a genetic abnormality which affects collagen in the bone, characterized by bones that break easily, often from no apparent cause.
- Idiopathic juvenile osteoporosis (IJO): no cause can be found.
- Marfan's and other collagen abnormalities
- Cerebral Palsy: If mobility (walking-weight bearing) is affected
- Wheelchair bound or bed bound: for 6 weeks or permanently as weight bearing is affected.
- Muscular Dystrophy: The secondary affects of mobility (walking) being affected.
- Juvenile arthritis or rheumatoid arthritis: the disease itself and steroids which is used to treat these diseases can affect bone and/or if the child's walking is impaired.
- Asthmatics: being treated with steroids: low dose, long-term or high dose short-term can place a child at risk.
- Idiopathic juvenile osteoporosis (IJO): no cause can be found.
- Malabsorption problems: such as coeliac disease and irritable bowel syndrome, can mean calcium, vitamin D and other nutrients are not properly absorbed from the intestine which affects bone.
- Ulcerative colitis and Chron's disease: the treatments are usually steroid based which affect bone.
- Corticosteroid medications: affect bone
- Chemotherapy or radiation: both affect bone
- Anorexia Nervosa and/or bulimia: past or present which affects bone.
- Over exercising: associated with inadequate nutrition resulting in loss of periods or no period: for more than 6 months (other than pregnancy) which affects bone.
- Amenorrhea: Athletes who have an eating disorder and who over train and therefore lose their periods, which affects bone.
- Thyrotoxicosis: overactive thyroid gland increases bone loss.
- Hypothyroid: under active thyroid, treatment with thyroxine must be monitored and can affect bone.
- Cushing's Syndrome: a condition in which your body makes too much of the hormone cortisol which can affect bone.
- Hyperparathyroidism: primary or secondary results in increased loss off bone.
- Rickets (osteomalacia): a severe vitamin D deficiency which affects bone.
- Diabetes: Insulin dependant.
Childhood and teenage years, are critical periods for developing a strong healthy skeleton, especially right before puberty between the ages of 8 and 12 years.
Research shows that bone can be significantly increased at this time and weight bearing activities should be encouraged.
Bone is made up of a strong collagen meshwork, with calcium deposited within it to make it hard. At millions of different sites throughout the skeleton, bone destroying cells called osteoclasts breakdown old bone and bone building cells called osteoblasts make up new bone.
In children, cells which make new bone work fast and as a result the skeleton structure increases in density and strength, especially when weight bearing/strengthening is included.
In young adults, there is a balance between the amount of bone tissue broken down and the amount replaced. From the age of 35-40 bone tissue breakdown increases and results in bone loss, this loss will increase more if risk factors are present.
Our genes mainly determine the potential height and strength of the skeleton but lifestyle factors can influence the amount of bone you build (peak bone mass). A good balanced diet, containing calcium rich foods and vitamin D, adequate proteins and calories, normal hormones, plus regular weight-bearing/strengthening exercise can help to make and maintain strong bones.
Peak bone strength is reached by the early 20's and stabilizes until the age of 35-40, when natural bone loss begins. If good peak bone strength is achieved in early childhood, the risk of osteoporosis in later life is reduced.
The best sources of calcium are milk and dairy products such as cheese and yogurt. Calcium can also be found in other foods such as bread, green leafy vegetables and baked beans. However, calcium is not as easily absorbed from these foods. Children between the ages of 3-21 years need the daily recommended intake of calcium and vitamin D, to help keep their bones healthy.
Vitamin D is needed to help the body to absorb calcium. Although foods such as dairy produce, margarine and fish oils contain vitamin D, the main source of this vitamin is usually from sunlight on skin. Approximately 15 minutes of sunlight a day during the summer months is adequate, so the risk of skin cancer is not increased.
Weight bearing/strengthening exercise can significantly help bones to increase their strength as this puts positive pressure on the bones, causing them to become stronger.
Impact loading exercise such as skipping, jumping, hopping, team sports and running are the best types of exercise for bone health, especially in young children. Research shows that weight bearing exercise especially right before puberty, can significantly improve bone density. Swimming and cycling are good all round exercises, but they have very little affect on bone becoming stronger, because the body is not supporting itself.
Bone health can be influenced in a negative way. A lifestyle involving over-exercising, excess alcohol, over-dieting, lack of daily amount of calcium and vitamin D and proteins or smoking, are ways in which the skeleton can be damaged.
Over-dieting can severely affect a growing skeleton, as if the calcium it needs during this crucial phase of development is not consumed. It can also disturb sex hormone levels which will also affect bone.
After puberty, teenage girls need adequate levels of the female sex hormone oestrogen for their bones to be protected. Excess dieting can decrease a person's body weight to the degree that oestrogen is no longer produced. A sign of this problem, is when periods become irregular or stop completely. Teenagers who have had no periods for 6 months or more are placing themselves at increased risk of developing osteopenia and/or osteoporosis at a very early age.
Osteopenia is the early stage of osteoporosis, the IOS has divided it up into three sections, mild, moderate and marked. Research shows that most people fracture in the moderate to marked Osteopenia range.
If periods do not start until after age 16, the skeleton can also suffer and so it is important to seek your GPs help in identifying the cause of any late onset of periods.
Over exercising in girls can work in a similar way to over-dieting, as it may lead to a reduction in body fat and body weight, this may result in irregular periods or periods stopping. Young women, who over-exercise, especially those who also have an eating disorder, are at a significantly increased risk of osteoporosis, unless action is taken to restore regular periods. We have 19 year olds with crushed vertebrae (bones in spine collapse causing a hump on upper back), secondary to anorexia. However they can significantly improve their bone health once diagnosed, to prevent fractures or to prevent further fractures.
Smoking damages the skeleton in addition to causing cancers. Smoking takes calcium from the bones and causes the body to lose the other essential vitamins and minerals it needs to grow.
Fizzy drinks containing phosphates are another problem with children, as acidic substances can leach calcium from the bones. Milk, especially those fortified with calcium and vitamin D, should be encouraged as well as water and healthy fruit juices.
The good news is that osteoporosis can be prevented and treated in most cases but it is critical to take action early. By building a strong skeleton during childhood and adolescence this will help to protect against bone loss and osteoporosis
in later life.
Establishing healthy eating and exercise habits in childhood, which should be continued throughout adulthood, is an important step to ensuring that our children do not become the next generation of osteoporosis sufferers.
Children are very prone to broken bones, however the majority of these fractures are usually due to an injury rather than osteoporosis. If a child breaks a bone (a low trauma) from a trip and fall, a questionnaire should be filled out to see if they have any risk factors for osteoporosis. If they have no risk factors, healthy eating including, adequate calories, calcium, vitamin D, proteins and weight bearing exercise should be encouraged. If a child fractures a second bone from a low trauma, it may be necessary to investigate further as the disease is a silent one.
How to find out if your child has osteoporosis?
If your child has had a broken bone after only a minor bump or has unexplained persistent back pain, it is important that you contact your GP to discuss the potential risk of osteoporosis. As it is a silent disease, it is important that it is ruled out.
- A risk assessment for osteoporosis should be filled out.
- He/she may refer your child to a specialist. Your child may be referred to an osteoporosis specialist, paediatric rheumatologist, paediatric orthopaedic surgeon or a paediatric endocrinologist.
- A DXA scan of the spine and hip to determine shape of bones.
- In order to exclude any underlying causes for the broken bones, blood and urine tests may be ordered.
- X-Rays may be taken to rule out fractures.
- An MRI scan, isotope bone scan, skin biopsy or a bone biopsy may be done to help make a diagnosis.
Treatments for Children
This depends on what is causing the osteoporosis and what can be done to reduce the affect it has on the child's bone health. Usually lifestyle changes are the main treatment for children. These include the following:
It is essential that every child gets the recommend daily amount of calcium and vitamin D for healthy bones. Please see nutrition section.
If your child is lactose intolerant or does not like dairy products or can not get the required daily amount of calcium and vitamin D, calcium and vitamin D supplements may be recommended depending on the child's risk of osteoporosis.
Calcium is difficult to absorb without vitamin D, which helps its absorption. When the sun is out, 15 minutes of sunlight on the face and arms is recommended as sun provides a natural source of vitamin D. Between the months of April and September children should be encouraged to play outside, weather permitting.
Bring your child's DXA results to a Chartered physiotherapist (society for chartered physiotherapist 01 4022148) with an interest in bone health so that they can initiate an appropriate exercise programme to improve your child's bone health.
Manipulations are not usually recommended for people with osteoporosis as the bones are weak to begin with.
Weight bearing and strengthening exercise is essential, but should be done on an individualized basis and should be based on DXA scan results, medical history, cause/s of osteoporosis and the ability of the child. Contact sports such as rugby and hurling are usually not recommended due to the increased risk of fracture. Skateboarding, ice-skating and skiing would not usually be recommended. It is important that children be encouraged to lead as normal a life as possible.
Swimming is good exercise, as it can help to strengthen muscles; however, it is not weight-bearing and therefore should not be the only form of exercise.
Alendronate, Clodronate, Etidronate and Pamidronate are all types of bisphosphonates. Research shows these drugs help to reduce the activity of osteoclasts, which are the bone clearing cells, in adults. There is some concern about prescribing them for children as they stay in the skeleton for an unknown amount of time and we do not know what their long term effect may be. However, in some children with osteoporosis they may be the best treatment option, compared to their risk of multiple fractures.
If your child has a growth hormone deficiency, replacement therapy may be advised by the specialist.
After a thorough and detailed investigation, in select cases of delayed puberty, testosterone or oestrogen may be used to treat boys and girls. This type of treatment must be monitored closely because it brings on puberty. It can cause unwanted side effects, for example, it may result in reduced adult height.
Monitoring response to treatment
Usually, a yearly check up is required to monitor the child's response to treatment. A DXA scan is usually done every 1 to 2 years, to help the specialist evaluate the child's response to treatment, so adjustments can be made as necessary.