Stimulant use and bone health in US children and adolescents: analysis of the NHANES data

Breaking It Down: A Systematic Review Unravelling the Impact of Attention Deficit Hyperactivity Disorder and Methylphenidate on Childhood Fractures

Limb fractures are a common cause of pediatric hospital admissions and surgeries, with a significant prevalence in the United Kingdom across all injury categories. Among psychiatric conditions in children, attention deficit hyperactivity disorder (ADHD) stands out as frequently associated with fractures, particularly those involving extremities. ADHD, with diagnoses prevalent among a significant proportion of school-age children and adolescents, has witnessed a growing global incidence. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 checklist for our systematic literature search, using various databases and specific search terms related to ADHD and fractures. We considered articles from 2018 to 2023, focusing on English language papers with free full-text access. Our selection process used the PRISMA flowchart. We began with 1,890 articles and, after deduplication, title screening, abstract assessment, and quality evaluation included nine research papers in our review. Our primary focus was on examining fracture-related outcomes in individuals with ADHD compared to those without, considering medication status. These studies encompassed various designs, with a focus on the ADHD-fracture relationship and methylphenidate's (MPH) impact. Our study confirms that ADHD increases fracture risk and suggests that MPH may help mitigate this risk. Early ADHD detection is vital for nonpharmacological interventions. Orthopedic surgeons should proactively identify ADHD, while healthcare professionals should offer injury prevention guidance, particularly for at-risk groups.

Influence of psychostimulants on bone mineral density and content among children with attention deficit hyperactivity disorder. A systematic review

There is a controversy over the influence of psychostimulant medications on bone mineral density (BMD) and bone mineral content (BMC) among children with attention-deficit-hyperactivity-disorder (ADHD). The aim of the present systematic review was to assess the influence of psychostimulant medications on BMD and BMC among children with ADHD. A comprehensive search of electronic databases, including PubMed, Scopus, Embase, and Cochrane Library, was conducted to identify relevant studies published up until July 2023. Clinical studies that addressed the focused question "Do psychostimulant medications affect bone mineral density and content in children with ADHD?" were included. Letters to the Editor, studies on animal-models, ex-vivo and in-vitro studies, commentaries and reviews were excluded. The primary outcome measures were changes in BMD and BMC. Study quality was assessed using the risk of bias for non-randomized studies-exposure tool. Five non-randomized clinical studies were included. The number of participants ranged from 18 to 6489 with mean ages ranging from 7.3 to 13.75 years. The study durations ranged between five and seven years. In all studies osseous evaluation was done using dual-energy X-ray absorptiometry. The bone locations examined included total body, lumbar-spine, femur, femoral-neck, femoral body, and pelvis. Two studies reported that psychostimulant medications reduce BMC and BMD. In one study, bone turnover, serum leptin and fat levels were reduced in children using psychostimulant medications but no unusual reduction recorded among controls. In general, 80 % of the studies concluded that psychostimulant medications compromise BMC and BMD. Power analysis was done in one study. One study had a low RoB and the remaining demonstrated some concerns. Given the methodological concerns observed in the included studies, arriving at a definitive conclusion regarding the effects of psychostimulant medications on BMC, BMD, and bone turnover in children with ADHD is challenging. However, it is important to acknowledge that an association between psychostimulant medications and these bone-related parameters cannot be disregarded.

Association between urinary methylparaben level and bone mineral density in children and adolescents aged 8-19 years

Previous epidemiological study has explored a positive association between methylparaben (Mep) and bone mineral density (BMD) in adults. Evidence linking Mep and BMD in children and adolescents is very limited. This study examined the association between Mep and BMD in children and adolescents aged 8-19 years. In this cross-sectional study, 1830 children and adolescents aged 8-19 years from NHANES 2011-2016 were analyzed. Mep was ln-transformed for analysis of the skewed distribution. Multiple linear regression analyses were performed to evaluate Mep's association with BMD (containing total BMD, trunk bone BMD, pelvis BMD, lumbar spine BMD, and thoracic spine BMD). Moreover, a generalized additive model (GAM) and a fitted smoothing curve (penalized spline method) were conducted to explore the exact shape of curve between them. In the fully adjusted model, ln-transformed Mep and BMD showed an independent and positive association (total BMD (β = 0.003, 95% CI (0.001, 0.005), P = 0.01), trunk bone BMD (β = 0.002, 95% CI (0.000, 0.005), P = 0.04), pelvis BMD (β = 0.004, 95% CI (0.001, 0.008), P = 0.02), lumbar spine BMD (β = 0.005, 95% CI (0.001, 0.008), P = 0.01), thoracic spine BMD (β = 0.003, 95% CI (0.001, 0.005), P = 0.02)) and a linear association. Subgroup analysis showed positive association between ln-transformed Mep and BMD. Furthermore, the positive association was significant in females and children aged 12-19 years (P for trend < 0.05). This study is the first study to find evidence demonstrating that exposure to Mep may be positively associated with BMD in children and adolescents aged 8-19 years. Validation of our findings will need further research.

Increased fracture risk among children diagnosed with attention- deficit/hyperactivity disorder: a large matched cohort study

To analyse the risk of fractures among children with attention-deficit/hyperactivity disorder (ADHD) compared with matched children without ADHD; and to evaluate the impact of pharmacological treatment. This registry-based cohort study included 31,330 children diagnosed with ADHD and a comparison group of 62,660 children matched by age, sex, population sector and socioeconomic status. Demographic and clinical information was extracted from the electronic database of Meuhedet, a health maintenance organization. Fracture events between 2-18 years of age were identified by coded diagnoses. The overall fracture incidence rate was 334 per 10,000 patient-years (PY) in the ADHD group and 284 per 10,000 PY in the comparison group (p < 0.001). Among boys, the fracture incidence rates were 388 per 10,000 PY and 327 per 10,000 PY (p < 0.001), for the respective groups. Among girls, the rates were lower in both groups compared to boys, but higher in the ADHD compared to the matched group (246 vs 203 per 10,000 PY, p < 0.001). Among the children with ADHD, the hazard ratios (HR) to have a fracture were similar in boys (1.18, 95%CI 1.15-1.22, p < 0.001) and girls (1.22, 95%CI 1.16-1.28, p < 0.001). Children with ADHD were also at increased risk for two and three fractures; the hazard ratios (HRs) were 1.32 (95%CI 1.26-1.38, p < 0.001) and 1.35 (95%CI 1.24-1.46, p < 0.001), respectively. In a multivariable model of the children with ADHD, pharmacological treatment was associated with reduced fracture risk (HR 0.90, 95%CI 0.82-0.98, p < 0.001) after adjustment for sex, resident socioeconomic status and population sector.   Conclusion: Children with ADHD had greater fracture risk than a matched group without ADHD. Pharmacological treatment for ADHD may decrease this risk. What is Known: • Children with attention-deficit/hyperactivity disorder (ADHD) may be more prone to injuries and fractures than children without ADHD. What is New: • Children with ADHD were 1.2 times more likely to have a fracture than children with similar characteristics, without ADHD. The increased risk for fractures was even greater for two and three fractures (hazard ratios 1.32 and 1.35, respectively). • Our study suggests a positive effect of pharmacological treatment for ADHD in reducing fracture risk.

Bone health in avoidant/restrictive food intake disorder: a narrative review

BACKGROUND

Avoidant/restrictive food intake disorder (ARFID) is an eating/feeding disturbance characterized by severe food avoidance or restriction that results in faltering growth, nutritional deficiencies, dependence on formula supplementation, and/or significant psychosocial impairment. Compared to other eating disorders, ARFID is observed to have an earlier childhood onset and chronic course without intervention. Childhood represents a sensitive period for longitudinal growth and bone accrual, setting the stage for long-term health outcomes associated with longevity and quality of life, including risk for fracture and osteoporosis.

RESULTS

This narrative review discusses published scientific literature on bone health in individuals with ARFID by describing the current understanding of ARFID's effect on bone health, how common dietary constraints characteristic of ARFID may present unique risks to bone health, and the current clinical recommendations for bone health assessment. Reviewing what is known of clinical data from anorexia nervosa (AN) and similar cohorts, the chronicity and etiology of dietary restriction observed in ARFID are hypothesized to compromise bone health significantly. Although limited, examination of bone health in ARFID patients suggests children with ARFID tend to have shorter stature compared to healthy reference datasets and have lower bone density compared to healthy individuals, similar to those with AN. There remains a substantial knowledge gap in how ARFID may interrupt bone accrual during childhood and adolescence, and subsequent impact on attainment of peak bone mass and peak bone strength. The longitudinal effects of ARFID may be subtle and overlooked clinically in the absence of severe weight loss or growth stunting. Early identification and remediation of threats to bone mass accrual have significant personal and population-level implications.

CONCLUSION

For patients with ARFID, delayed identification and intervention to address feeding disturbances may have a long-lasting impact on various body systems and processes, including those relating to longitudinal growth and bone mass accrual. Further research employing rigorous prospective observational and/or randomized study designs are required to clearly define effects of ARFID, as well as clinical interventions aimed at addressing ARFID-related feeding disturbances, on bone accrual.

Fracture rates by medication type in attention-deficit/hyperactive disorder

Background

ADHD is a condition with extensively researched increased risks of psychiatric disorders, traumatic injury, impulsivity, and delayed response times.

Objectives

To analyze the incidences of fractures in patients with ADHD on various medication regimens.

Methods

Using the TriNetX database, we created seven patient cohorts, all of age under 25, based on medication types commonly used for ADHD. The cohorts we created were: no medication use, exclusive use of a -phenidate class stimulant, exclusive use of an amphetamine class stimulant, nonexclusive use of formations of either stimulant, exclusive use of non-stimulant medications approved for ADHD, nonexclusive use, and no medications. We then examined rates while controlling for age, sex, race, and ethnicity.

Results

The comparison of ADHD to neurotypical individuals revealed an increased risk for all fracture types. For the controlled analysis, all but one cohort had significant differences in each fracture type compared to the baseline cohort of ADHD patients without any medication use. Patients in the "phenidate" cohort had an insignificant difference in risk of lower limb fractures. Patients in the "any medication," "-etamine," "stimulant," and "not ADHD" groups all had significant decreased risks for all fracture types, with confidence intervals often overlapping between treatment modalities.

Conclusions

As patients experiment with different medication regimens, providers should be aware of the difference in risk of fracture by medication type. Our results highlight the need for continued research to better discern appropriate medication regimens with the goal of improving overall risk reduction and producing better outcomes for individuals with ADHD.

Influence of dietary patterns and physical activity on bone mineral content and density, osteoporosis among children with stimulant use

AIM

To examine the relationship between dietary patterns (DPs) and physical activity (PA) on bone mineral content (BMC), bone mineral density (BMD), and osteoporosis in children with stimulant use.

METHODS

A cross-sectional study collected information on participants from the National Health and Nutrition Examination Survey (NHANES) via multistage stratified sampling. The baseline variables included the following: age, gender, the dietary approaches to stop hypertension (DASH) score, the Mediterranean diet (MD) score, and the Alternative Healthy Eating Index-2010 (AHEI-2010). The univariate and multivariate linear-regression analyses were carried out to explore the statistical correlation between the DPs and PA on BMC and BMD in children with stimulant use or non-stimulant use. In addition, we also investigated the association between DPs and PA on osteoporosis via logistic regression analyses.

RESULTS

A total of 6,294 participants were eligibly enrolled in this study eventually. After adjusting age, gender, body mass index (BMI), race, family income, serum 25-hydroxyvitamin D, and serum cotinine, the multivariate linear-regression analysis showed that the MD was positively associated with total femur BMD, total femur BMC, femoral neck BMD, and femoral neck BMC among stimulant use group; high PA was associated with total femur BMD, total femur BMC, femoral neck BMD, femoral neck BMC, lumbar spine BMD, lumbar spine BMC and osteoporosis in stimulant use group.

CONCLUSION

Improved adherence to MD, DASH, AHEI-2010 or increased physical activity may increase BMD, BMC and reduce the risk of osteoporosis; children with stimulant use should improve their adherence to the MD and do more PA compared with children without stimulant use.