Is your Child or Teenager at risk of Osteoporosis?
Most people are shocked to hear that children can be affected by osteoporosis. At present, there are no statistics about this. However, no child should be left at risk of this disease.
Anyone under 21 years of age deemed to be at risk can only be scanned on a DXA machine that has the additional software for children. They will also need an X-ray of their non-dominant hand to be taken as it 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, characterised 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.
- Muscular Dystrophy: the secondary effects of mobility (walking) being affected.
- Juvenile arthritis or Rheumatoid arthritis: the disease itself and steroids which are 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.
- Malabsorption problems: such as Coeliac disease (Gluten and wheat sensitivity) 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: treatments are usually steroid based which affect bone.
- Corticosteroid medications: affects bone.
- Chemotherapy and/or Radiation: both affect bone.
- Anorexia Nervosa and/or Bulimia: past or present affects bone.
- Over exercising: associated with inadequate nutrition resulting in loss of periods or no period: for more than 4 months (other than pregnancy) affects bone.
- Amenorrhea: athletes who have an eating disorder and who over train and therefore lose their periods affects bone.
- Thyrotoxicosis: overactive thyroid gland increases bone loss.
- Hypothyroid: under active thyroid, treatment with thyroxine must be monitored as they can affect bone.
- Cushing’s Syndrome: a condition in which your body makes too much of the hormone cortisol can affect bone.
- Hyperparathyroidism: primary or secondary results in increased loss of bone.
- Rickets (osteomalacia): a severe vitamin D deficiency which affects bone.
- Diabetes: Insulin dependent.
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 (strength and quality) 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 for bone loss are present.
Our genes mainly determine the potential height and strength of our 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, as well as normal hormones, regular weight-bearing/strengthening exercise can help to make and maintain strong bones.
Peak bone strength is reached by the early 20’s and stabilises 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 and 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 products, margarine and fish oils contain vitamin D, the main source of this vitamin is usually from sunlight on skin. Approximately 15 minutes (this can be broken up into 3 sets of 5 minutes) of sunlight a day during the summer months is adequate. Make sure to put sun block on after this time, so the risk of skin cancer is not increased. Vitamin D from the sun is not advised if a person burns easily.
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 great all-round exercises. But they have very little effect 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 the daily amounts of calcium, vitamin D, proteins or smoking, are ways in which the skeleton can be damaged.
Over-dieting can severely affect a growing skeleton as this is a crucial time for bone development. It can also disturb sex hormone levels, which will affect bone and fertility.
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 4 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. There are three stages in regard to osteopenia: mild, moderate and marked. Research shows that most people fracture (break bones) in the moderate to marked Osteopenia range.
If periods do not start until after the age 15 the skeleton can also suffer, so it is important to seek a GP or Gynaecologists help in identifying the cause/s 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 the upper back) due to over exercising and/or eating disorders. 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 act 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, most 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 us, 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.
- Your child may need to be referred to an Osteoporosis specialist, Paediatric rheumatologist, Paediatric orthopaedic surgeon or a Paediatric endocrinologist.
- A DXA scan of the spine to determine the condition of their bones.
- 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, Vitamin D and protein for healthy bones. Please see nutrition section.
If your child is lactose intolerant or does not like dairy products supplements may be recommended, if the child cannot get the daily amounts from food.
Vitamin D is necessary for calcium absorption.
Manipulations are not usually recommended for those with osteoporosis.
Weight bearing and strengthening exercise is essential but should be done on an individualised 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 and the secondary effects of 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 one to two years to help the specialist evaluate the child’s response to treatment, so adjustments can be made as necessary.