Clinical review 1: Bisphosphonate use in childhood osteoporosis

ENDOCRINOLOGY AND ADOLESCENCE: Osteoporosis in children: diagnosis and management

Osteoporosis in children can be primary or secondary due to chronic disease. Awareness among paediatricians is vital to identify patients at risk of developing osteoporosis. Previous fractures and backaches are clinical predictors, and low cortical thickness and low bone density are radiological predictors of fractures. Osteogenesis Imperfecta (OI) is a rare disease and should be managed in tertiary paediatric units with the necessary multidisciplinary expertise. Modern OI management focuses on functional outcomes rather than just improving bone mineral density. While therapy for OI has improved tremendously over the last few decades, this chronic genetic condition has some unpreventable, poorly treatable and disabling complications. In children at risk of secondary osteoporosis, a high degree of suspicion needs to be exercised. In affected children, further weakening of bone should be avoided by minimising exposure to osteotoxic medication and optimising nutrition including calcium and vitamin D. Early intervention is paramount. However, it is important to identify patient groups in whom spontaneous vertebral reshaping and resolution of symptoms occur to avoid unnecessary treatment. Bisphosphonate therapy remains the pharmacological treatment of choice in both primary and secondary osteoporosis in children, despite limited evidence for its use in the latter. The duration and intensity of treatment remain a concern for long-term safety. Various new potent antiresorptive agents are being studied, but more urgently required are studies using anabolic medications that stimulate bone formation. More research is required to bridge the gaps in the evidence for management of paediatric osteoporosis.

Osteoporosis treatment with zoledronic acid in pediatric population at a university hospital in Western Saudi Arabia. A 13-year experience

Objectives:

To highlight the clinical benefit, efficacy, and safety of zoledronic acid (ZA) therapy in children and adolescents with primary and secondary osteoporosis.

Methods:

This is a retrospective observational study of 131 children and adolescents visiting the Pediatric Endocrine Clinic at King Abdulaziz University Hospital, Jeddah, Kingdom of Saudi Arabia, between January 2002 and January 2015. Clinical and laboratory data were collected for each patient and adverse events were evaluated.

Results:

The mean patient age was 11.43 years. There was a significant decrease in the number of fractures after ZA treatment for primary osteoporosis (p=0.000) and in secondary osteoporosis (p=0.005). There was a significant decrease in both osteocalcin (p=0.001) and C-terminal telopeptide (p=0.003) in patients with primary osteoporosis, as well as osteocalcin (p=0.003) and C-terminal telopeptide (p=0.008) in patients with secondary osteoporosis after treatment.

Conclusion:

The use of ZA in children and adolescent appears to have favorable effects on fracture rate and quality of life, including pain and mobility in symptomatic individuals. Intravenous ZA is comparable to other bisphosphonate agents in its efficacy and safety and features a more convenient infusion protocol with no documented long-term complications, thus, we advise its use in pediatric population.

Enamel permeability and resistance to acid challenges after systemic use of sodium alendronate: a study in rat teeth

OBJECTIVES

To evaluate the enamel resistance and permeability of rat teeth to acid challenges after systemic use of sodium alendronate.

MATERIALS AND METHODS

Eighteen Wistar rats (36 teeth), aged 36-42 days (200-230 g), were assigned into two groups: alendronate group (n = 20 teeth), which received two weekly doses of 1 mg/kg of alendronate, via gavage; and a non-alendronate group (n = 16 teeth), which received only distilled water. After 60 days, the animals were killed, the maxillary incisors were extracted and used for the artificial induction of the caries lesion (pH cycling regimen) and erosion area (immersion cycles in cola-type soft drink) and for the enamel permeability test (dye penetration). The teeth were divided into alendronate group (n = 10) or non-alendronate group (n = 8) for each test. The quantitative response variables were the percent longitudinal change in Knoop microhardness (%LMC), the enamel carious/erosion lesion area (CELA) and enamel permeability.

RESULTS

Groups were not significantly different (p > 0.05) with regard to the %LMC and enamel permeability (25.58 μm ± 12.73 and 25.40 μm ± 4.6 for the experimental and control groups, respectively). For CELA, it was not observed significant difference (p > 0.05) between the non-alendronate group (24.08 ± 1.36 and 25.22 ± 1.60, for caries and erosion, respectively) and the alendronate group (25.46 ± 1.60 and 25.0 ± 1.26) for caries and erosion, respectively).

CONCLUSIONS

Based on the methodological conditions and the presented results of this study, sodium alendronate did not affect the longitudinal microhardness, demineralisation lesion area or permeability of the enamel after acid challenge; therefore, alendronate did not become the enamel of rats more resistant.

CLINICAL RELEVANCE

The systemic alendronate treatment for 60 days did not change the enamel of rats regarding the susceptibility to acids.

The consequences of pediatric renal transplantation on bone metabolism and growth

PURPOSE OF REVIEW

During childhood, growth retardation, decreased final height and renal osteodystrophy are common complications of chronic kidney disease (CKD). These problems remain present in patients undergoing renal transplantation, even though steroid-sparing strategies are more widely used. In this context, achieving normal height and growth in children after transplantation is a crucial issue for both quality of life and self-esteem. The aim of this review is to provide an overview of pathophysiology of CKD-mineral bone disorder (MBD) in children undergoing renal transplantation and to propose keypoints for its daily management.

RECENT FINDINGS

In adults, calcimimetics are effective for posttransplant hyperparathyroidism, but data are missing in the pediatric population. Fibroblast growth factor 23 levels are associated with increased risk of rejection, but the underlying mechanisms remain unclear. A recent meta-analysis also demonstrated the effectiveness of rhGH therapy in short transplanted children.

SUMMARY

In 2013, the daily clinical management of CKD-MBD in transplanted children should still focus on simple objectives: to optimize renal function, to develop and promote steroid-sparing strategies, to provide optimal nutritional support to maximize final height and avoid bone deformations, to equilibrate calcium/phosphate metabolism so as to provide acceptable bone quality and cardiovascular status, to correct all metabolic and clinical abnormalities that can worsen both bone and growth (mainly metabolic acidosis, anemia and malnutrition), promote good lifestyle habits (adequate calcium intake, regular physical activity, no sodas consumption, no tobacco exposure) and eventually to correct native vitamin D deficiency (target of 25-vitamin D >75 nmol/l).

Zoledronic Acid for the Treatment of Children With Refractory Central Giant Cell Granuloma

There are no approved medical therapies for the treatment of pediatric central giant cell granuloma (CGCG), a benign but potentially aggressive tumor of the jaw. Zoledronic acid (ZA), a third-generation bisphosphonate, has been used in CGCG occurring in adults. We describe 4 patients with CGCG treated with ZA, 3 of whom achieved resolution of disease up to 4 years of follow-up. Our experience suggests that ZA may be considered as treatment for pediatric CGCG.

Bisphosphonate treatment of children and adults with osteogenesis imperfecta: unanswered questions

Bisphosphonates are extensively used for treatment of children and adults with osteogenesis imperfecta. Over years, studies have reported the response of BP treatment in individuals with OI but some questions remain still unanswered.

The use of bisphosphonates in pediatrics

Bisphosphonates are widely used for the prevention and treatment of osteoporosis in adulthood. In the last years, bisphosphonates have been increasingly used in pediatric patients for the treatment of a growing number of disorders associated with osteoporosis, resistant hypercalcemia or heterotopic calcifications. The use of bisphosphonates in pediatric patients has been proven safe; however, the risk of potential severe consequences into adulthood should be kept in mind. Well-defined criteria for bisphosphonates treatment in pediatric patients are not specified, therefore an accurate selection of patients who could benefit from bisphosphonates is mandatory. A strict follow-up of pediatric patients receiving long-term bisphosphonate therapy is strongly recommended. The purpose of this mini review is to provide a summary of current knowledge on some main general aspects of the structure, mechanisms of action, pharmacokinetics, and bioavailability of bisphosphonates, and to focus on the latest advances of bisphosphonate treatment in pediatric patients. Particular attention has been paid to the common and potential adverse effects of bisphosphonate treatment, and some suggestions concerning the clinical approach and general measures for bisphosphonate treatment in pediatric patients are reported.

Bone density assessment in a tertiary paediatric centre over 13 years: Referral patterns and limitations

AIM

This study aims to examine the referral practices for the Royal Children's Hospital (RCH) bone density service over the past 13 years and to demonstrate referral patterns and possible limitations to accessing paediatric bone densitometry.

METHODS

All patients attending the RCH Healthy Bones Unit for bone densitometry from 1 July 1999 to 30 June 2012, aged under 18 years of age, were included. Densitometry results were downloaded directly from the Hologic scanner into an Excel document. However, the referring unit and indication for referral were collected manually from either the referral card or the hospital's scanned medical records system.

RESULTS

A total of 5767 bone densitometry scans were performed over the study period on 3004 patients. The majority of referrals were made by the Endocrinology department, followed by Adolescent Medicine, Gastroenterology and Neurology. Relatively few referrals were made by general paediatrics. The most common indication for bone density test overall was eating disorders, followed by steroid use, osteogenesis imperfecta and other collagen disorders and inflammatory bowel disease. The lowest lumbar spine z-scores by indication were for cerebral palsy and other causes of immobility.

CONCLUSIONS

Multiple childhood diseases predispose to low bone density; however, paediatric bone densitometry is still underutilised and not appropriately supported by subsidies.

Bisphosphonate therapy in pediatric patients

Although for many decades bisphosphonates were used for adult bone loss, bisphosphonate administration in pediatric patients is new and was initiated in the past 15-year. The indications for pediatric bisphosphonates was extended to childhood malignancies with bone involvement, after additional effects were unveiled for bisphosphonates with recent research. In this article we review childhood bone loss and conditions with bone involvement in which bisphosphonate therapy have been used. We also review mechanisms of action of bisphosphonates, and present indications of bisphosphonate therapy in pediatric patients based on results of clinical trials.

Fracture during intravenous bisphosphonate treatment in a child with osteogenesis imperfecta: an argument for a more frequent, low-dose treatment regimen

BACKGROUND/AIMS

Intravenous bisphosphonate therapy is the mainstay of medical treatment in osteogenesis imperfecta (OI) and has been shown to increase bone mass, decrease bone pain, improve mobility, and reduce the incidence of fractures. Sclerotic metaphyseal lines parallel to the growth plate are seen on long bone radiographs following cyclical intravenous therapy. These areas create stress risers within the bone that may act as foci for subsequent fractures as exemplified in this clinical case.

METHODS

An 8-year-old girl with OI sustained a distal radial fracture following 3 years of treatment with 6-monthly intravenous zoledronate. Her diagnosis, response to treatment, and subsequent fracture at a sclerotic metaphyseal line is described.

RESULTS

Peripheral quantitative computer tomography was used to characterise the presence of multiple stress risers at the distal forearm. Trabecular bone mineral density fluctuated from 34 to 126% compared to neighbouring 2-mm regions.

CONCLUSION

There remain many unanswered questions about optimal bisphosphonate treatment regimens in children with OI. The formation of stress risers following intravenous bisphosphonate treatment raises the hypothesis that a more frequent and low-dose bisphosphonate regimen would provide more uniform dosing of bone in the growing child and reduce the likelihood of fractures compared to current treatment practices.

Diagnosis and treatment of pediatric osteoporosis

PURPOSE OF REVIEW

Progress toward identifying and treating disorders of bone fragility in pediatric patients has been considerable in recent years. This article will summarize several key advances in the management of osteoporosis in children and adolescents.

RECENT FINDINGS

Recommendations from the 2013 pediatric Position Development Conference provide expert guidance for evaluating bone health in younger patients. The diagnosis of pediatric osteoporosis can be made in a child with low-trauma vertebral fractures or a combination of low bone mass and long bone fractures. Management of bone fragility includes optimizing nutrition, activity, and treatment of the underlying disease. Pharmacologic agents can be considered if these measures fail to prevent further bone loss or fractures. Although the efficacy and safety of several intravenous and oral bisphosphonates have been examined, there is still no consensus on the optimal drug, dose, or duration of treatment. Observational studies of children with secondary osteoporosis provide insight into risk factors for fracture or the potential for recovery.

SUMMARY

Despite advances in the diagnosis and treatment of pediatric osteoporosis, more research is needed. Randomized controlled trials of pharmacologic agents should be defined to target those identified at the highest risk by observational studies.

VIDEO ABSTRACT

http://links.lww.com/COE/A9

Therapies for children with cerebral palsy: A Web of Science-based literature analysis

OBJECTIVE:

To identify global research trends in three therapies for children with cerebral palsy.

DATA RETRIEVAL:

We performed a bibliometric analysis of studies on therapies for children with cerebral palsy from 2002 to 2011 retrieved from Web of Science.

SELECTION CRITERIA:

Inclusion criteria: (a) peer-reviewed published articles on botulinum toxin, constraint-induced movement therapy, or acupuncture for children with cerebral palsy indexed in Web of Science; (b) original research articles, reviews, meeting abstracts, proceedings papers, book chapters, editorial material, and news items; and (c) publication between 2002 and 2011. Exclusion criteria: (a) articles that required manual searching or telephone access; (b) documents that were not published in the public domain; and (c) a number of corrected papers from the total number of articles.

MAIN OUTCOME MEASURES:

(1) Number of publications on the three therapies; (2) annual publication output, distribution by journals, distribution by institution, and top-cited articles on botulinum toxin; (3) annual publication output, distribution by journal, distribution by institution, and top-cited articles on constraint-induced movement therapy; (4) annual publication, distribution by journal, distribution by institution, and top-cited articles on acupuncture.

RESULTS:

This analysis, based on Web of Science articles, identified several research trends in studies published over the past 10 years of three therapies for children with cerebral palsy. More articles on botulinum toxin for treating children with cerebral palsy were published than the articles regarding constraint-induced movement therapy or acupuncture. The numbers of publications increased over the 10-year study period. Most papers appeared in journals with a focus on neurology, such as Developmental Medicine and Child Neurology and Journal of Child Neurology. Research institutes publishing on botulinum toxin treatments for this population are mostly in the Netherlands, the United States of America, and Australia; those publishing on constraint-induced movement therapy are mostly in Australia and the United States of America; and those publishing on acupuncture are mostly in China, Sweden and the United States of America.

CONCLUSION:

Analysis of literature and research trends indicated that there was no one specific therapy to cure cerebral palsy. Further studies are still necessary.

[Advances in the treatment of secondary osteoporosis]

Osteoporosis is being increasingly recognised in paediatric practice as a consequence of the increasing life expectancy of children who suffer from chronic diseases and other factors. There are many non-pharmacological measures that can improve children' bone health, for example, avoiding inflammatory activity and osteotoxic treatments; increasing sun exposure and weight-bearing exercise, and maintaining an adequate nutritional status. Vitamin D and calcium supplements have been proposed as a measure to increase bone mass, but their effect and therapeutic indications are not completely clear. On the other hand, bisphosphonates are currently the only pharmacological alternative for the patients with infantile secondary osteoporosis. However, more studies are required on the therapeutic indications, posology, and long term secondary effects of biphosphonates. The aim of this article is to analyze the scientific evidence of the effectiveness of the therapeutic alternatives for childhood secondary osteoporosis and their safety in children.

Multiple atraumatic osteoporotic vertebral fractures in an adolescent with suprasellar germinoma: a case report

ABSTRACT

We present the case of a patient with multiple atraumatic osteoporotic vertebral fractures in an adolescent with suprasellar germinoma and also review of relevant literature. The patient suffered from a rare adolescent brain tumour with common complications which are often overlooked and give rise to significant morbidity. Suprasellar germinoma is an intracranial neoplasm, that in addition to its rarity, has variable clinical presentation. Despite appropriate treatment and good outcome, tumour related morbidity is still of concern for these patients.

KEY WORDS

Secondary osteoporosis, suprasellar germinoma, panhypopituitarism.

Optimizing bone health in children and adolescents

The pediatrician plays a major role in helping optimize bone health in children and adolescents. This clinical report reviews normal bone acquisition in infants, children, and adolescents and discusses factors affecting bone health in this age group. Previous recommended daily allowances for calcium and vitamin D are updated, and clinical guidance is provided regarding weight-bearing activities and recommendations for calcium and vitamin D intake and supplementation. Routine calcium supplementation is not recommended for healthy children and adolescents, but increased dietary intake to meet daily requirements is encouraged. The American Academy of Pediatrics endorses the higher recommended dietary allowances for vitamin D advised by the Institute of Medicine and supports testing for vitamin D deficiency in children and adolescents with conditions associated with increased bone fragility. Universal screening for vitamin D deficiency is not routinely recommended in healthy children or in children with dark skin or obesity because there is insufficient evidence of the cost-benefit of such a practice in reducing fracture risk. The preferred test to assess bone health is dual-energy x-ray absorptiometry, but caution is advised when interpreting results in children and adolescents who may not yet have achieved peak bone mass. For analyses, z scores should be used instead of T scores, and corrections should be made for size. Office-based strategies for the pediatrician to optimize bone health are provided. This clinical report has been endorsed by American Bone Health.

Osteogenesis imperfecta: diagnosis and treatment

Osteogenesis imperfecta (OI) is a genetic bone fragility disorder characterized by low bone mass, skeletal deformity, and variable short stature. OI is predominantly caused by dominant mutations affecting type 1 collagen synthesis, with a number of other genes implicated in OI over recent years. The clinical severity of OI can vary greatly, even within families who share a common mutation. Optimal management of OI requires a multidisciplinary approach involving pediatrician, endocrinologist (bone and mineral physician), rehabilitation specialist, orthopedic surgeon, dentist, geneticist, social worker/psychologist, physiotherapist, and occupational therapist. Bisphosphonate therapy remains the mainstay of medical treatment in OI and has been shown to decrease bone pain, enhance well-being, improve muscle strength and mobility and decrease fracture incidence. Novel therapies are beginning to emerge as more is understood about the signaling pathways involved in bone formation. The following summarizes the diagnosis, genetic heterogeneity and management of OI in pediatric practice.

Underweight, overweight, and pediatric bone fragility: impact and management

Skeletal health is modulated by a variety of factors, including genetic makeup, hormonal axes, and environment. Across all ages, extremes of body weight may exert a deleterious effect on bone accretion and increase fracture risk. The incidence of both anorexia nervosa and obesity, each involving extreme alterations in body composition, is rising among youth, and secondary osteoporosis is increasingly being diagnosed among affected children and adolescents. Compared with the elderly, the definition of osteoporosis that stems from any underlying condition differs for the pediatric population and special precautions are required with regard to treatment of young patients. Early recognition and management of both underweight and overweight youth and the accompanying consequences on bone and mineral metabolism are essential for preservation of skeletal health, although prevention of bone loss and optimization of bone mineral accrual remain the most important protective measures.

Identification, prevention, and treatment of children with decreased bone mineral density

Osteoporosis in children is the presence of decreased bone mineral density in association with a significant fracture history. The amount of bone accretion in childhood and early adulthood is predictive of the risk of osteoporosis and fracture in later adulthood. A myriad of disorders and medications are associated with decreased bone mineral density in childhood. In addition, lifestyle factors including poor dietary habits and minimal physical activity are associated with low bone mass. Because of the limited attention given to childhood osteoporosis, this review was undertaken to examine the diagnostic criteria, etiologies, prevention of and treatment strategies for osteoporosis in children and adolescents.

Glucocorticoid-associated osteoporosis in chronic inflammatory diseases: epidemiology, mechanisms, diagnosis, and treatment

Children with chronic illnesses such as Juvenile Idiopathic Arthritis and Crohn's disease, particularly when taking glucocorticoids, are at significant risk for bone fragility. Furthermore, when childhood illness interferes with achieving normal peak bone mass, life-long fracture risk is increased. Osteopenia and osteoporosis, which is increasingly recognized in pediatric chronic disease, likely results from numerous disease- and treatment-related factors, including glucocorticoid exposure. Diagnosing osteoporosis in childhood is complicated by the limitations of current noninvasive techniques such as DXA, which despite its limitations remains the gold standard. The risk:benefit ratio of treatment is confounded by the potential for spontaneous restitution of bone mass deficits and reshaping of previously fractured vertebral bodies. Bisphosphonates have been used to treat secondary osteoporosis in children, but limited experience and potential long-term toxicity warrant caution in routine use. This article reviews the factors that influence loss of normal bone strength and evidence for effective treatments, in particular in patients with gastrointestinal and rheumatologic disorders who are receiving chronic glucocorticoid therapy.

Treatment of osteoporosis in children with glucocorticoid-treated diseases

Glucocorticoid induced osteoporosis (GIO) is the most frequent form of drug induced osteoporosis. Glucocorticoids affect osteoblastogenesis, osteoclastogenesis and promote the apoptosis of osteoblasts and osteocytes. A decrease of bone mineral density has been described in several pediatric diseases that require glucocorticoids, both as long-term replacement therapy, such as Congenital Adrenal Hyperplasia, and as treatment of acute phase or relapses, such as asthma, juvenile rheumatoid arthritis, inflammatory bowel diseases, systemic lupus erythematosus, organ transplantation and Steroid Sensitive Nephrotic Syndrome. The increasing number of children with GIO and at risk of fractures reflects the complex nature of this condition, and the need of development of anti-osteoporotic drugs. In this review, we focus on the mechanisms of GIO in some pediatric diseases and on treatment of osteoporosis. We also report data on new signaling pathways as potential targets for future anti-osteoporotic drugs.

Treatment of osteogenesis imperfecta in adults

BACKGROUND

Osteogenesis imperfecta (OI) is a heterogeneous rare connective tissue disorder commonly caused by mutations in the collagen type I genes. Pharmacological treatment has been most extensively studied in children, and there are only few studies comprising adult OI patients.

OBJECTIVES

i) To review the literature on the current medical management of OI in children and adults, and thereby identify unmet medical needs and ii) to present an overview of possible future treatment options.

RESULTS

Individualization and optimization of OI treatment in adults remain a challenge, because available treatments do not target the underlying collagen defect, and available literature gives weak support for treatment decisions for adult patients.

CONCLUSIONS

Bisphosphonates are still the most widely used pharmacological treatment for adult OI, but the current evidence supporting this is sparse and investigations on indications for choice and duration of treatment are needed.

Isolated growth hormone deficiency (GHD) in childhood and adolescence: recent advances

The diagnosis of GH deficiency (GHD) in childhood is a multistep process involving clinical history, examination with detailed auxology, biochemical testing, and pituitary imaging, with an increasing contribution from genetics in patients with congenital GHD. Our increasing understanding of the factors involved in the development of somatotropes and the dynamic function of the somatotrope network may explain, at least in part, the development and progression of childhood GHD in different age groups. With respect to the genetic etiology of isolated GHD (IGHD), mutations in known genes such as those encoding GH (GH1), GHRH receptor (GHRHR), or transcription factors involved in pituitary development, are identified in a relatively small percentage of patients suggesting the involvement of other, yet unidentified, factors. Genome-wide association studies point toward an increasing number of genes involved in the control of growth, but their role in the etiology of IGHD remains unknown. Despite the many years of research in the area of GHD, there are still controversies on the etiology, diagnosis, and management of IGHD in children. Recent data suggest that childhood IGHD may have a wider impact on the health and neurodevelopment of children, but it is yet unknown to what extent treatment with recombinant human GH can reverse this effect. Finally, the safety of recombinant human GH is currently the subject of much debate and research, and it is clear that long-term controlled studies are needed to clarify the consequences of childhood IGHD and the long-term safety of its treatment.

Intravenous zoledronic Acid given every 6 months in childhood osteoporosis

AIM

To evaluate the safety and efficacy of 12 months of zoledronic acid (ZA) administered every 6 months to children with osteoporosis.

METHODS

Retrospective cohort study of 27 patients (16 male, 11 female) treated with ZA (0.05 mg/kg/dose) every 6 months for 1 year. 20 were immobile, 4 steroid-induced osteoporosis, 2 idiopathic osteoporosis and 1 neurofibromatosis type 1. 16 had long bone fractures and 12 had vertebral wedging at baseline. Mineral homeostasis, bone mineral density (BMD) and vertebral morphometry were evaluated at baseline and 12 months. Results were compared to published data on 3-monthly ZA treatment.

RESULTS

Median age at ZA start was 10.5 years (range 6.2-13.3). Following the first infusion, 2 developed asymptomatic hypocalcemic, 14 developed temperature > 38°C, 13 aches/pain and 6 nausea. At 12 months, there was reduction in bone turnover and improvement in BMD and vertebral shape. No patient fractured after starting ZA. Growth was normal. Outcomes were similar to 3-monthly ZA.

CONCLUSION

ZA administered 6-monthly was associated with acute phase reaction to the first dose and improvement in BMD, reduction in bone turnover and improved vertebral shape at 12 months.

2014 Female Athlete Triad Coalition consensus statement on treatment and return to play of the female athlete triad: 1st International Conference held in San Francisco, CA, May 2012, and 2nd International Conference held in Indianapolis, IN, May 2013

The Female Athlete Triad is a medical condition often observed in physically active girls and women, and involves 3 components: (1) low energy availability with or without disordered eating, (2) menstrual dysfunction, and (3) low bone mineral density. Female athletes often present with 1 or more of the 3 Triad components, and an early intervention is essential to prevent its progression to serious endpoints that include clinical eating disorders, amenorrhea, and osteoporosis. This consensus statement represents a set of recommendations developed following the first (San Francisco, California) and second (Indianapolis, Indianna) International Symposia on the Female Athlete Triad. It is intended to provide clinical guidelines for physicians, athletic trainers, and other health care providers for the screening, diagnosis, and treatment of the Female Athlete Triad and to provide clear recommendations for return to play. The 2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad Expert Panel has proposed a risk stratification point system that takes into account magnitude of risk to assist the physician in decision-making regarding sport participation, clearance, and return to play. Guidelines are offered for clearance categories, management by a multidisciplinary team, and implementation of treatment contracts. This consensus paper has been endorsed by The Female Athlete Triad Coalition, an International Consortium of leading Triad researchers, physicians, and other health care professionals, the American College of Sports Medicine, and the American Medical Society for Sports Medicine.

The use of bisphosphonates in children: review of the literature and guidelines for dental management

Bisphosphonates are inhibitors of osteoclastic bone resorption with therapeutic benefit in a variety of bone disorders in both adults and children. While these agents have been routinely used in adults for the past three decades, their more recent introduction into paediatric medicine means there is a paucity of data on long-term safety and effects on dental development. There is uncertainty regarding the dental management of children treated with bisphosphonates, particularly when invasive dental procedures, such as extractions and oral surgical procedures, are required. There are limited data with which to make recommendations about the dental management of patients treated with bisphosphonates, and there are no published recommendations that specifically address paediatric patients. This paper aims to outline paediatric uses and adverse effects of bisphosphonates and present recommendations on the dental management of children receiving bisphosphonates.

Successful treatment of a sacral aneurysmal bone cyst with zoledronic acid

BACKGROUND

Aneurysmal bone cysts (ABCs) in the sacrum pose a management challenge as their location usually means that surgical excision is not possible. Strategies such as embolization have been used previously but have the potential for significant side effects. We report the successful use of bisphosphonate treatment (zoledronic acid) in an 8-year-old boy who presented with an ABC that did not respond to embolization.

METHODS

The patient presented with pain and progressive limp. After radiologic and histologic confirmation of the diagnosis, embolization therapy was trialed, which was unsuccessful. At this point, he had severe pain and extremely limited mobility, requiring the use of a wheelchair. His ability to lie flat or sit erect was limited by the pain. Zoledronic acid therapy was subsequently commenced at 0.04 mg/kg per dose by intravenous infusion, at 4 monthly intervals, for a total of 2 years (7 doses).

RESULTS

The infusions were well tolerated, with rapid reduction in pain and resolution of previously severe immobility, from being bed and chair bound at baseline to normal independent ambulation over several months. This was associated with marked radiologic improvement. We postulate that the effect of treatment is a combination of the anti-inflammatory effect of zoledronic acid and the antiresorptive effect of osteoclast inhibition.

CONCLUSIONS

We conclude that bisphosphonates should be considered as possible second-line agents for ABCs. Further, study of a larger cohort would help to establish their efficacy in this setting.

LEVEL OF EVIDENCE

Level IV (case report, no comparator/control arm).

Glucocorticoid-induced osteoporosis: an update on effects and management

Glucocorticoids remain a cornerstone of guideline-based management of persistent asthma and allergic diseases. Glucocorticoid-induced osteoporosis (GIO) is the most common iatrogenic cause of secondary osteoporosis and an issue of concern for physicians treating patients with inhaled or oral glucocorticoids either continuously or intermittently. Patients with GIO experience fragility fractures at better dual-energy x-ray absorptiometry T-scores than those with postmenopausal or age-related osteoporosis. This might be explained, at least in part, by the effects of glucocorticoids not only on osteoclasts but also on osteoblasts and osteocytes. Effective options to detect and manage GIO exist, and a management algorithm has been published by the American College of Rheumatology to provide treatment guidance for clinicians. This review will summarize GIO epidemiology and pathophysiology and assess the role of inhaled and oral glucocorticoids in asthmatic adults and children, with particular emphasis on the effect of such therapies on bone health. Lastly, we will review the American College of Rheumatology GIO guidelines and discuss diagnostic and therapeutic strategies to mitigate the risk of GIO and fragility fractures.

Muscle strength, joint range of motion, and gait in children and adolescents with osteogenesis imperfecta

PURPOSE

To analyze clinical and functional features of children and adolescents with osteogenesis imperfecta (OI).

METHODS

A cross-sectional study of 62 participants examined clinical, body structure and function and activity features.

RESULTS

A total of 31 participants had OI type I, 9 had type III, and 22 had type IV. Mild (type I) and moderate/severe (types III and IV) OI differed significantly in occurrence of fractures, presence of bone deformities, the use of intramedullary rods, bone mineral density, and bisphosphonate therapy. Age of gait acquisition showed an association with overall joint range of motion and an inverse relationship with overall muscle strength. Level of ambulation was associated with overall muscle strength and inversely associated with overall joint range of motion.

CONCLUSIONS

Features vary according to OI type. Moderate and severe forms of OI are associated with greater functional limitation, influenced by fracture history, which negatively affects the acquisition and level of ambulation.

Bisphosphonate Treatment in a Patient Affected by MPS IVA with Osteoporotic Phenotype

Morquio A syndrome (Mucopolysaccharidosis type IVA) (MPS IVA) is a rare inherited metabolic disorder characterized by the defective degradation of keratan sulfate and chondroitin-6-sulfate. Classically, MPS IVA patients present with severe multisystemic involvement and have a short life expectancy. Attenuated forms with clinical features limited to minor skeletal abnormalities and short stature have also been described, sometimes associated to an early-onset osteoporotic phenotype. No treatment with allogenic bone marrow transplantation or gene therapy is currently available for Morquio A syndrome, and enzyme replacement therapy is under evaluation. We report a case of MPS IVA, who manifested tardily attenuated phenotype and significant bone mass reduction, which was treated with a bisphosphonate (BPN), resulting in an improvement of X-ray skeletal aspects and functional bone performance. We suggest that the use of bisphosphonates may be an interesting supportive therapeutic option for Morquio A patients with osteoporotic phenotype, but further studies involving more patients are necessary to confirm our findings.

Whole-exome sequencing reveals a heterozygous LRP5 mutation in a 6-year-old boy with vertebral compression fractures and low trabecular bone density

Juvenile osteoporosis (JO) is characterized by bone fragility during development, low bone mass and absence of extraskeletal features. Heterozygous loss-of-function mutations in LRP5 have been found in a few patients, but bone tissue and bone material abnormalities associated with such mutations have not been determined. Here we report on a 6-year-old boy who presented with a history of seven low-energy long-bone fractures starting at 19months of age and absence of extraskeletal involvement. Spine radiographs revealed multiple vertebral compression fractures. Despite tall stature (95th percentile), lumbar spine areal bone mineral density was low (z-score=-3.2). Trabecular volumetric bone mineral density, measured by peripheral quantitative computed tomography at the distal radius, was low (z-score=-5.1), but cortical thickness at the radial diaphysis was normal. Iliac bone histomorphometry demonstrated low bone formation activity in trabecular but not in cortical bone. Quantitative backscattered electron imaging showed normal material bone density in trabecular bone, but elevated results in the cortex. Whole-exome sequencing revealed a heterozygous insertion of a nucleotide in exon 12 of LRP5. This mutation had previously been reported in another JO patient and had been shown to lead to nonsense-mediated decay. Thus, heterozygous loss-of-function mutations in LRP5 can be associated with a bone formation deficit that affects mostly the trabecular compartment and can result in bone fragility during the first years of life.

Bisphosphonate-related osteonecrosis of the jaws and its relevance to children--a review

Bisphosphonate-related osteonecrosis of the jaws (BRONJ) has been detailed extensively in adults, but to date, there have been no similar cases in children. Members of the dental team may treat children prescribed bisphosphonate therapy often for management of osteogenesis imperfecta (OI). There is uncertainty as to how best treat this patient group. This review explores the background of bisphosphonates, indications for their prescription in children, adverse effects with special emphasis on BRONJ, and protocols available to guide dental management.

A practical guide to the monitoring and management of the complications of systemic corticosteroid therapy

Systemic corticosteroids play an integral role in the management of many inflammatory and immunologic conditions, but these agents are also associated with serious risks. Osteoporosis, adrenal suppression, hyperglycemia, dyslipidemia, cardiovascular disease, Cushing’s syndrome, psychiatric disturbances and immunosuppression are among the more serious side effects noted with systemic corticosteroid therapy, particularly when used at high doses for prolonged periods. This comprehensive article reviews these adverse events and provides practical recommendations for their prevention and management based on both current literature and the clinical experience of the authors.

Diagnosis of Osteoporosis in Children and Adolescents

Osteoporosis is traditionally regarded as a disease of elderly women. However, this bone disorder occurs in patients of both sexes and of all ages and is also increasingly recognised in the paediatric setting. In particular, patients, including young children, with other chronic diseases are at risk of developing bone fragility. There are also several forms of hereditary osteoporosis, which should be identified at an early stage to ensure adequate treatment. The diagnosis of osteoporosis in children is challenging, since their bone mineral density (BMD) is affected by growth and pubertal development. In addition to low BMD, a child must also exhibit a significant proneness to fractures before the osteoporosis diagnosis can be made. Through early diagnosis and treatment for paediatric bone fragility, we can also ameliorate bone health in adulthood. In this article we review the aetiology, known risk factors and the diagnostic criteria of osteoporosis in the young.

Bone health in children and adolescents with perinatal HIV infection

The long-term impact on bone health of lifelong HIV infection and prolonged ART in growing and developing children is not yet known. Measures of bone health in youth must be interpreted in the context of expected developmental and physiologic changes in bone mass, size, density and strength that occur from fetal through adult life. Low bone mineral density (BMD) appears to be common in perinatally HIV-infected youth, especially outside of high-income settings, but data are limited and interpretation complicated by the need for better pediatric norms. The potential negative effects of tenofovir on BMD and bone mass accrual are of particular concern as this drug may be used more widely in younger children. Emphasizing good nutrition, calcium and vitamin D sufficiency, weight-bearing exercise and avoidance of alcohol and smoking are effective and available approaches to maintain and improve bone health in all settings. More data are needed to inform therapies and monitoring for HIV-infected youth with proven bone fragility. While very limited data suggest lack of marked increase in fracture risk for youth with perinatal HIV infection, the looming concern for these children is that they may fail to attain their expected peak bone mass in early adulthood which could increase their risk for fractures and osteoporosis later in adulthood.

Prevention of steroid-induced low bone mineral density in children with renal diseases: a systematic review

BACKGROUND

Children with renal diseases who are treated with glucocorticoids are at increased risk of developing osteoporosis and fractures. However, there is no common strategy for prevention of corticosteroid-induced osteoporosis. The present systematic review was performed to determine whether prevention of bone loss by calcium (Ca), vitamin D (vit D) and/or bisphosphonates is justified, safe and efficacious in children treated with steroids for various renal diseases.

METHODS

DATA SOURCES

Medline, Embase, Central were searched from 1961 up to 2012. Randomized controlled trials (RCTs) and observational studies concerning children ≤18 years with renal diseases requiring steroids were included.

RESULTS

The search strategy retrieved 2482 studies. Four RCTs including 166 patients and one observational study including 100 children met our eligibility criteria. One RCT and the observational study concerned treatment with Ca/vit D, one RCT with bisphosphonates and two RCTs with a combination of both therapies. All described a significant improvement in bone mineral density (BMD) in the treatment group compared with the control group.

CONCLUSIONS

 Ca combined with vit D is recommended to prevent bone disease in children with renal diseases treated with steroids. Because of side effects, bisphosphonates should be reserved for the treatment of severe osteoporosis when Ca and/or vit D supplementation has failed.

Reduced RANKL expression impedes osteoclast activation and tooth eruption in alendronate-treated rats

The creation of the eruption pathway requires the resorption of the occlusal alveolar bone by osteoclasts and signaling events between bone and dental follicle are necessary. The aim of the present study has been to evaluate the effect of alendronate on osteoclastogenesis and the expression of the regulator proteins of osteoclast activation, namely RANK, RANKL and OPG, in the bone that covers the first molar germ. Newborn Wistar rats were treated daily with 2.5 mg/kg alendronate for 4, 8, 14, 21 and 28 days, whereas controls received sterile saline solution. At the time points cited, maxillae were fixed, decalcified and processed for light and electron microscopic analysis. TRAP histochemistry was performed on semi-serial sections and the osteoclasts in the occlusal half of the bony crypt surface were counted. TUNEL analysis was carried out on paraffin sections. The occlusal bone that covers the upper first molar was removed in additional 4- and 8-day-old alendronate-treated and control rats in which the expression of RANK, RANKL and OPG was analyzed by SDS-polyacrylamide gel electrophoresis and Western blotting. TRAP-positive osteoclasts were more numerous in the alendronate group at all time points, despite their unactivated phenotype and the presence of apoptotic cells. RANKL expression in the alendronate specimens was inhibited at all time points, unlike in controls. Our findings indicate that the expression of RANKL in the occlusal portion of the bony crypt is unrelated to osteoclast recruitment and differentiation but is crucial to their activation during the creation of the eruption pathway.

Fractures in hospitalized children

Hospitalized children have multiple risk factors for fragility fractures, related to disease pathophysiology, treatments, nutritional status and immobilization. Recognition and treatment of these risk factors are important to prevent morbidity associated with fractures and to promote current and future bone health. Many knowledge gaps remain regarding the ideal nutrition, physical activity, and medication regimens needed to optimize bone health and reduce the risk of fractures over the life course. This article reviews the pathogenesis, risk factors, treatment and prevention strategies for fractures in hospitalized infants and children.

Idiopathic juvenile osteoporosis: a cross-sectional single-centre experience with bone histomorphometry and quantitative computed tomography

BACKGROUND

Idiopathic juvenile osteoporosis (IJO) is a rare condition of poorly understood etiology and pathophysiology that affects otherwise healthy children. This condition is characterized clinically by bone pain and vertebral fractures; spontaneous recovery is observed after puberty in the majority of cases. Although decreased trabecular bone turnover has been noted previously, cortical and trabecular bone characteristics as determined by quantitative computed tomography (QCT) and their relationship to bone histomorphometry are unknown.

METHODS

All children with a clinical diagnosis of IJO who were followed in our center since 1995 and who had undergone at least one diagnostic bone biopsy were included in this cross-sectional analysis.

RESULTS

Fifteen patients (11 males/4 females) with median ages of 5.8 and 10.2 years at first symptoms and at referral, respectively, were included in the analysis. Histomorphometric analysis demonstrated decreased trabecular bone turnover (BFR/BS) in the majority of patients with heterogeneous parameters of trabecular mineralization and volume. QCTresults demonstrated that bone mineral density (BMD) was reduced in both trabecular/lumbar and cortical/femoral bone: Z score: -2.1 (-3.6;-1.0) and -0.9 (-8.2;1.4)in the two compartments, respectively. In the eight patients who underwent both bone biopsy and QCT, cortical BMD was associated with trabecular separation and with trabecular bone formation rate (r = 0.898 and -0.881, respectively, both p < 0.05).

CONCLUSIONS

This series confirms that IJO is characterized by impaired trabecular architecture that can be detected by both bone biopsy and QCT. The association between bone biopsy and QCT results may have implications for diagnosis, treatment, and follow-up of these children.

Allele dependent silencing of collagen type I using small interfering RNAs targeting 3'UTR Indels - a novel therapeutic approach in osteogenesis imperfecta

Osteogenesis imperfecta, also known as "brittle bone disease", is a heterogeneous disorder of connective tissue generally caused by dominant mutations in the genes COL1A1 and COL1A2, encoding the α1 and α2 chains of type I (pro)collagen. Symptomatic patients are usually prescribed bisphosphonates, but this treatment is neither curative nor sufficient. A promising field is gene silencing through RNA interference. In this study small interfering RNAs (siRNAs) were designed to target each allele of 3'UTR insertion/deletion polymorphisms (indels) in COL1A1 (rs3840870) and COL1A2 (rs3917). For both indels, the frequency of heterozygous individuals was determined to be approximately 50% in Swedish cohorts of healthy controls as well as in patients with osteogenesis imperfecta. Cultures of primary human bone derived cells were transfected with siRNAs through magnet-assisted transfection. cDNA from transfected cells was sequenced in order to measure targeted allele/non-targeted allele ratios and the overall degree of silencing was assessed by quantitative PCR. Successful allele dependent silencing was observed, with promising results for siRNAs complementary to both the insertion and non-insertion harboring alleles. In COL1A1 cDNA the indel allele ratios were shifted from 1 to 0.09 and 0.19 for the insertion and non-insertion allele respectively while the equivalent resulting ratios for COL1A2 were 0.05 and 0.01. Reductions in mRNA abundance were also demonstrated; in cells treated with siRNAs targeting the COL1A1 alleles the average COL1A1 mRNA levels were reduced 65% and 78% compared to negative control levels and in cells treated with COL1A2 siRNAs the average COL1A2 mRNA levels were decreased 26% and 49% of those observed in the corresponding negative controls. In conclusion, allele dependent silencing of collagen type I utilizing 3'UTR indels common in the general population constitutes a promising mutation independent therapeutic approach for osteogenesis imperfecta.

Vitamin D status in pediatric patients with a history of malignancy

BACKGROUND

Multiple studies associate low vitamin D levels with cancer morbidity and mortality. However, few studies have measured vitamin D in pediatric patients with malignancy. Our aim was to assess vitamin D status in a large cohort of pediatric patients with cancer and to define risk factors for deficiency.

METHODS

Circulating 25-hydroxyvitamin D (25OHD) levels were measured in 211 patients. Calcium intake and sun exposure habits were assessed in 142 patients (age 12.1 ± 5.8 y; number of male patients, 69; mean time from diagnosis, 4.4 ± 3.8 y).

RESULTS

Daily calcium intake was 66.2 ± 39.3% of the recommended daily allowance. Mean 25OHD levels were 20.6 ± 7.9 ng/ml. Vitamin D deficiency (<15 ng/ml) was found in 24.6% of the patients and insufficiency (15-20 ng/ml) in 23.2%. Younger age and amount of sun exposure were associated with higher serum 25OHD. No association was found with calcium intake, disease type, gender, BMI SD score, years since diagnosis, or stem cell transplantation. The 25OHD levels during winter were significantly lower than the summer levels.

CONCLUSION

The prevalence of vitamin D deficiency and insufficiency in pediatric patients with a history of malignancy was high, whereas calcium intake was low. These findings are concerning, given the risk for osteoporosis in this population and the possible role of vitamin D in the context of malignancy.

A displaced femoral neck stress fracture in an amenorrheic adolescent female runner

This case demonstrates the potential serious consequences of the female athlete triad and its effects on bone. Displaced femoral neck stress fractures cause significant morbidity, and this case highlights the preventable nature of this injury. The treatment was focused on improving low energy availability, and, although challenging, improvements were made. This injury could have been prevented if the signs and symptoms of her injury had been addressed and there had been better knowledge of her risk factors. This case highlights the need for further education in the sports and health communities.

Pamidronate for the treatment of osteoporosis secondary to chronic cholestatic liver disease in Wistar rats

Osteoporosis is a major complication of chronic cholestatic liver disease (CCLD). We evaluated the efficacy of using disodium pamidronate (1.0 mg/kg body weight) for the prevention (Pr) or treatment (Tr) of cholestasis-induced osteoporosis in male Wistar rats: sham-operated (Sham = 12); bile duct-ligated (Bi = 15); bile duct-ligated animals previously treated with pamidronate before and 1 month after surgery (Pr = 9); bile duct-ligated animals treated with pamidronate 1 month after surgery (Tr = 9). Rats were sacrificed 8 weeks after surgery. Immunohistochemical expression of IGF-I and GH receptor was determined in the proximal growth plate cartilage of the left tibia. Histomorphometric analysis was performed in the right tibia and the right femur was used for biomechanical analysis. Bone material volume over tissue volume (BV/TV) was significantly affected by CCLD (Sham = 18.1 ± 3.2 vs Bi = 10.6 ± 2.2%) and pamidronate successfully increased bone volume. However, pamidronate administered in a preventive regimen presented no additional benefit on bone volume compared to secondary treatment (BV/TV: Pr = 39.4 ± 12.0; Tr = 41.2 ± 12.7%). Moreover, the force on the momentum of fracture was significantly reduced in Pr rats (Sham = 116.6 ± 23.0; Bi = 94.6 ± 33.8; Pr = 82.9 ± 22.8; Tr = 92.5 ± 29.5 N; P < 0.05, Sham vs Pr). Thus, CCLD had a significant impact on bone histomorphometric parameters and pamidronate was highly effective in increasing bone mass in CCLD; however, preventive therapy with pamidronate has no advantage regarding bone fragility.