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

Sleep characteristics in underweight young females across their menstrual cycles: A sleep-monitoring survey study with preliminary results

This study investigated the association between underweight and sleep in young females across their menstrual cycles. A lifestyle-monitoring survey was conducted among 38 female university students aged 18-24 years in Japan from January to December 2023. Sleep data from 28 participants were analysed. Participants were categorized into underweight (n = 10) and control (n = 18) groups based on a baseline body mass index cut-off of 18.5 kg m-2. Sleep parameters were assessed using a daily sleep questionnaire, sleep sensor mats, and urinary melatonin metabolites across their menstrual cycles. The results indicated no significant differences in sleep patterns between the underweight and control groups or menstrual cycle phases, as assessed using both the daily sleep questionnaire and the sleep sensor mats. However, underweight participants experienced more difficulty maintaining sleep during the follicular phase. Body mass index significantly correlated with sleep efficiency (rs = 0.52) and wake after sleep onset (rs = -0.56). While urinary melatonin metabolite levels did not differ significantly between the groups or menstrual cycle phases, decreased levels during the luteal phase were more prevalent in the underweight group (7 of 10 participants) than in the control group (3 of 13 participants). This study suggests an association between underweight and sleep quality, especially nocturnal awakening, in young females. These findings underscore the importance of considering sleep quality in the management of underweight young females to improve their overall health outcomes.

Age- and height-dependent bias of underweight and overweight assessment standards for children and adolescents

Background

Precision in evaluating underweight and overweight status among children and adolescents is paramount for averting health and developmental issues. Existing standards for these assessments have faced scrutiny regarding their validity. This study investigates the age and height dependencies within the international standards set by the International Obesity Task Force (IOTF), relying on body mass index (BMI), and contrasts them with Japanese standards utilizing the percentage of overweight (POW).

Method

We scrutinized a comprehensive database comprising 7,863,520 children aged 5-17 years, sourced from the School Health Statistics Research initiative conducted by Japan's Ministry of Education, Culture, Sports, Science, and Technology. Employing the quantile regression method, we dissected the structure of weight-for-height distributions across different ages and sexes, quantifying the potentially biased assessments of underweight and overweight status by conventional criteria.

Results

Applying IOFT criteria for underweight assessment revealed pronounced height dependence in males aged 11-13 and females aged 10-11. Notably, a discernible bias emerged, wherein children in the lower 25th percentile were classified as underweight five times more frequently than those in the upper 25th percentile. Similarly, the overweight assessment displayed robust height dependence in males aged 8-11 and females aged 7-10, with children in the lower 25th percentile for height deemed obese four or five times more frequently than their counterparts in the upper 25th percentile. Furthermore, using the Japanese POW criteria for assessment revealed significant age dependence in addition to considerably underestimating the percentage of underweight and overweight cases under the age of seven. However, the height dependence for the POW criterion was smaller than the BMI criterion, and the difference between height classes was less than 3-fold.

Conclusion

Our findings underscore the intricacies of age-dependent changes in body composition during the growth process in children, emphasizing the absence of gold standards for assessing underweight and overweight. Careful judgment is crucial in cases of short or tall stature at the same age, surpassing sole reliance on conventional criteria results.

Body Mass Index Is Associated With Pediatric Complicated Appendicitis and Postoperative Complications

OBJECTIVE

To investigate the association between body mass index (BMI) spectrum and complicated appendicitis and postoperative complications in pediatric patients.

BACKGROUND

Despite the impact of being overweight and obese on complicated appendicitis and postoperative complications, the implications of being underweight are unknown.

METHODS

A retrospective review of pediatric patients was conducted using NSQIP (2016-2020) data. Patient's BMI percentiles were categorized into underweight, normal weight, overweight, and obese. The 30-day postoperative complications were grouped into minor, major, and any. Univariate and multivariable logistic regression models were performed.

RESULTS

Among 23,153 patients, the odds of complicated appendicitis were 66% higher in underweight patients [odds ratio (OR)=1.66; 95% CI: 1.06-2.59] and 28% lower in overweight patients (OR=0.72; 95% CI: 0.54-0.95) than normal-weight patients. A statistically significant interaction between overweight and preoperative white blood cells (WBCs) increased the odds of complicated appendicitis (OR=1.02; 95% CI: 1.00-1.03). Compared to normal-weight patients, obese patients had 52% higher odds of minor (OR=1.52; 95% CI: 1.18-1.96) and underweight patients had 3 times the odds of major (OR=2.77; 95% CI: 1.22-6.27) and any (OR=2.82; 95% CI: 1.31-6.10) complications. A statistically significant interaction between underweight and preoperative WBC lowered the odds of major (OR=0.94; 95% CI: 0.89-0.99) and any complications (OR=0.94; 95% CI: 0.89-0.98).

CONCLUSIONS

Underweight, overweight, and interaction between overweight and preoperative WBC were associated with complicated appendicitis. Obesity, underweight, and interaction between underweight and preoperative WBC were associated with minor, major, and any complications. Thus, personalized clinical pathways and parental education targeting at-risk patients can minimize postoperative complications.

Evaluation of bone mineral density and bone turnover in children on anticoagulation

Background

Childhood and adolescence are critical periods of bone mineral acquisition. Children on anticoagulation (AC) might have an increased risk for reduced bone mineral density (BMD). Risk factors for impaired bone accumulation include chronic diseases, immobility, and medication. Vitamin K (VK) deficiency reflected by undercarboxylated osteocalcin levels (ucOC) has been identified as a predictor of osteoporosis and fractures. Data on bone health in children under AC are sparse.

Aims

To evaluate BMD in children on AC and characterize the risk factors of low BMD, including VK and Vitamin D (VD) status.

Methods

Single-center cross-sectional study of clinical, biochemical, and densitometric parameters. Assessment of VK surrogate parameters included ucOC and matrix gla protein (MGP).

Results

A total of 39 children (4-18 years; 12 females) receiving AC were included, 31 (79%) on VK antagonists and 8 (21%) on direct oral anticoagulants. Overall, BMD was decreased for both the lumbar spine (LS; -0.7SDS) and total body less head (TBLH; -1.32SDS) compared with pediatric reference data. Significant associations were found between early pubertal development and TBLH-BMD, and between BMI and LS-BMD. VK surrogate parameters were highly related to patients' age and pubertal development. Neither serum parameters nor AC-related factors predicted BMD. VD was detected in 10/39 patients with lower values during puberty.

Conclusion

Our data indicate BMD reduction in pediatric patients on AC. Although AC-related factors did not predict reduced BMD, low BMI and pubertal stages represented important risk factors. Awareness of risk factors for low BMD and high prevalence of VD deficiency during puberty could contribute to the improvement of bone health in this vulnerable patient group.

Fracture prevalence and its association with bone density among children living with HIV in Zimbabwe

OBJECTIVES

HIV infection impairs bone density in children living with HIV (CLWH). We aimed to determine the prevalence of self-reported fracture (past or current), associated risk factors and disability, by HIV status in Zimbabwean children.

DESIGN

Cross-sectional study.

METHODS

We recruited CLWH aged 8-16 years taking antiretroviral therapy (ART) for ≥2 years from HIV clinics, and HIV-uninfected children from schools in Harare. Interviewer-administered questionnaires collected data on fracture site and management, sociodemographics, dietary calcium and vitamin D, physical activity and HIV history. Dual-energy X-ray absorptiometry (DXA) measured size-adjusted bone density.

RESULTS

We recruited 303 CLWH [mean (SD) age 12.5 (2.5) years; 50% female] and 306 children without HIV [12.5 (2.5) years; 51% female]. Median age at HIV diagnosis in CLWH was 3.0 years [interquartile range (IQR) 1.2, 5.9], and median ART duration 8.1 years [IQR 6.2, 9.5]. 53.8% CLWH had self-reported disability and/or functional impairment, vs. 29.4% children without HIV. Fracture prevalence was 5.9% with no difference by HIV status [21/306 (6.9%) vs. 14/303 (4.6%), P  = 0.24]. Male sex was associated with fractures. Low size-adjusted bone density ( Z -score < -2) was associated with prevalent fractures in CLWH {risk ratio [RR] 1.14 (95% confidence interval (CI) -0.02, 2.29]}, but not in children without HIV [RR -0.04 (-2.00, 1.91)], P -interaction = 0.27. All sought medical attention for their fracture(s), but CLWH were less often admitted to hospital [2/14 (14.3%) vs. 7/21 (33.3%)].

CONCLUSION

Prevalent fractures may be associated with low lumbar spine bone density in CLWH. Fracture surveillance and strategies to reduce future fracture risk are warranted as CLWH enter adulthood.

Relationship Between Hypovitaminosis D and Fractures Among Adolescents With Overweight or Obesity

Adolescents with overweight/obesity are at risk for vitamin D insufficiency and deficiency. Both overweight/obesity and vitamin D insufficiency/deficiency may predispose to fractures. We enrolled 103 participants (53.3% females, 15.9 ± 2.2 years) in a retrospective case-control study to determine whether an association exists between fractures and a low 25-hydroxyvitamin D (25[OH]D) among adolescents whose body mass index (BMI) ≥ 85 percentile. Cases (n = 28) sustaining a low/medium impact fracture were matched to controls (n = 75) without a fracture history. A conditional-logistic regression analysis addressing the common vitamin D insufficiency/deficiency cutoffs was used. Overweight, obesity, and significant obesity rates were 10.7%, 53.4%, and 35.9%, respectively. Mean (±SD) 25(OH)D was 16.5 ± 6.4 ng/mL. In all, 25(OH)D insufficiency rates (level <20 ng/mL) were 70.5%. Matched cases and controls had similar 25(OH)D insufficiency/deficiency rates (P > .05). Controlling for race and seasonality showed no association between fractures and 25(OH)D insufficiency/deficiency (P > .05). These data suggest that fractures are not associated with low 25(OH)D levels among adolescents whose BMI ≥ 85th percentile.

The Insidious Effects of Childhood Obesity on Orthopedic Injuries and Deformities

The current childhood obesity epidemic, affecting approximately 20% of American children and adolescents, is accompanied by unique orthopedic manifestations. The growing musculoskeletal system is susceptible to the endocrine effects of obesity, resulting in decreased bone mass and quality. As a result, obese children are at increased risk of musculoskeletal injury, fracture, and lower extremity deformities. The efficacy of nonoperative treatment such as casting or bracing may be limited by body habitus and surgical treatment is accompanied by increased risk of perioperative complications.

Evaluating and optimizing bone health in children with chronic health conditions

Paediatric health care providers (HCPs) play an important role in optimizing bone health. Early intervention is essential to maximize the accrual of peak bone mass in adolescence and young adulthood and to reduce osteoporosis and fracture risk later in life. Children and adolescents with chronic health conditions may have several risk factors for poor bone health, including underlying inflammatory conditions, reduced weight-bearing activity, delayed puberty, and inadequate intake of calcium and vitamin D. Some medications-particularly glucocorticoids-can compromise bone mass and place a child at risk for fragility fractures. This practice point describes a targeted approach to identifying bone health risk factors in children and youth with chronic health conditions, highlights office initiatives aimed at optimizing bone mass accrual, and links HCPs to useful web-based tools and medical references. Indications for referral to a bone health specialist and bone-specific pharmacotherapeutic interventions are also reviewed.

L'évaluation et l'optimisation de la santé osseuse chez les enfants ayant des affections chroniques

Les professionnels de la santé des enfants jouent un rôle important dans l'optimisation de la santé osseuse. Il est essentiel d'intervenir rapidement pour maximiser le pic de masse osseuse à l'adolescence et au début de l'âge adulte et d'ainsi réduire le risque d'ostéoporose et de fractures plus tard dans la vie. Les enfants et les adolescents ayant une affection chronique peuvent présenter plusieurs facteurs de risque de mauvaise santé osseuse, notamment des maladies inflammatoires sous-jacentes, des activités avec mise en charge limitées, un retard pubertaire et un apport insuffisant de calcium et de vitamine D. Certains médicaments, et particulièrement les glucocorticoïdes, peuvent compromettre la masse osseuse et exposer l'enfant à un risque de fractures de fragilisation. Le présent point de pratique décrit une approche ciblée pour déterminer les facteurs de risque liés à la santé osseuse chez les enfants et les adolescents ayant une affection chronique, expose les mesures à prendre en cabinet pour optimiser l'acquisition de la masse osseuse et propose des outils en ligne utiles et des références médicales à l'intention des professionnels de la santé des enfants. Les indications pour diriger les patients vers un spécialiste de la santé osseuse et pour procéder à des interventions pharmacologiques visant les os sont également abordées.

Determinants of Bone Mineral Density in Transgender Youth

Purpose

We aimed to study determinants of bone health in transgender youth in anticipation of or shortly after initiating puberty suppression and/or gender-affirming hormone therapy.

Methods

This was a retrospective review of records of transgender adolescents in our institution between June 2014 and June 2019. Dual energy X-ray absorptiometry was used to assess bone mineral density (BMD). Baseline characteristics were collected and included in a multilinear regression model to assess determinants of lumbar spine (LS) BMD Z-scores adjusted for age and height and accounting for race. Welch's t-test was used to compare characteristics across genders.

Results

One hundred nineteen patient records were analyzed. Forty-six patients (38.7%) were assigned male at birth (AMAB) and 73 patients (61.3%) were assigned female at birth (AFAB). Mean (±standard deviation [SD]) age (years) was 14.7±2.6 for AMAB and 15.0±2.2 for AFAB. The adjusted LS BMD Z-score was lower in the AMAB population with a mean (+SD) of -0.605±1.42 compared with 0.043±1.09 in AFAB (p=0.010). In a multivariate model, AMAB gender, vitamin D deficiency, and lower body mass index (BMI) z-scores were determinants of lower LS BMD Z-scores (R ²=0.206). Age, race, ethnicity, insurance status, and Tanner stage were not determinants of BMD. However, post hoc analysis did show that pubertal status modified the results.

Conclusion

AMAB transgender adolescents have lower BMD compared with AFAB patients, before or shortly after starting puberty suppression and/or gender-affirming hormone therapy. Lower BMI and vitamin D deficiency were determinants of lower BMD. Further studies are needed to explore etiology for bone health discrepancy in this population.

Nutritional status and associated factors of older persons in sub-Saharan Africa: a scoping review

BACKGROUND

The older person population is rapidly increasing globally, including sub-Saharan Africa (SSA). Concurrently, malnutrition is also increasing among older persons in SSA, with a dearth of empirical evidence on nutritional status and associated factors among the older persons in the region to inform effective interventions to promote healthy ageing.

AIM/OBJECTIVE

This review assessed the nutritional status and associated factors among older persons in SSA.

METHOD

PubMed, Google Scholar, and Cochrane Library electronic databases were searched for published articles from 2010 to 2021 using keywords and Boolean logic. Also, we carried out a free web-based search to retrieve other relevant evidence that assesses the older persons' nutritional status. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow chart was used to appraise the research articles that responded to the study's research questions.

FINDINGS

Twenty studies met the inclusion criteria, from which data were extracted as findings. The malnutrition prevalence was between 6 to 54% among older persons in SSA. We found that the prevalence of malnutrition vary and could be as high as 28.4% in a low socio-economic status area. Of these studies, twelve (12) provided data on undernutrition with prevalence ranging from 2.9 to 41%;10 provided data on overweight (8.1-54.1%) and 5 on obesity (2.7-44.7%). Seventeen of the studies evaluated factors associated with malnutrition; 4 studies revealed the association between socioeconomic status and malnutrition, 7 studies reported a significant association between dietary habits and malnutrition. Four studies showed an association between educational status and malnutrition. Disease conditions associated with malnutrition were reported in four of the studies.

CONCLUSION

This review shows that malnutrition is a problem among older persons in SSA coupled with many risk factors which should be given critical attention. We recommend nutrition education for older persons as well as the development of nutrition interventions for this vulnerable group.

The relationship between extremity fractures and visual impairment in childhood: A case-control study

BACKGROUND

Fractures are common extremity injuries in pediatric orthopedic practice. The aim of this study is to determine the relationship between pediatric extremity fractures and visual impairments.

METHODS

Thirty pediatric patients who were admitted to the emergency and orthopedics and traumatology clinic due to an extremity fracture after a fall were included in the study. Following fracture treatment, the patients were evaluated in terms of ocu-lar findings before discharge from the hospital. Thirty age- and sex-matched healthy children who presented to the ophthalmology department for routine care were also recruited as the control group. All participants underwent a comprehensive ophthalmologic examination, including cycloplegic refraction, visual acuity levels, and near stereoacuity measurement.

RESULTS

The number of male participants was higher in both groups. There was no significant difference between the groups in terms of age and gender distribution. The most common upper extremity fractures were observed to be distal radius (52%) and distal humerus fractures (28%). The number of patients who had a refractive error that required spectacles was significantly higher in the fracture group (p=0.039). When the visual acuity levels of the better eye were evaluated, the mean visual acuity was significantly lower in the fracture group (p=0.016). The mean stereoacuity was also significantly lower in the study group (<0.001). In the binary logistic regression analysis model, low stereopsis levels were associated with the risk of pediatric extremity fractures (95% CI: 1.056-1.385; p=0.006).

CONCLUSION

Our study showed that low-energy pediatric extremity fractures are more common in children with visual im-pairments that require treatment, and low stereopsis is a risk factor for fractures. Consequently, regular eye examinations and early treatment of visual impairments in children may help to prevent fall-related injuries.

The association of extreme body weight with bone mineral density in Saudi children

Objective:

The objective to investigate the effect of extreme body weight; obesity and undernutrition, on bone mineral density (BMD).

Methodology:

This study is a descriptive cross-sectional study carried between January and June of 2019, and included 224 children and adolescents without any comorbidities or chronic disease. Important data collected included anthropometrics, past medical and surgical history, history of medication intake, level of physical activity and pubertal assessment. Data entry and analysis were conducted using Statistical Package for Social Sciences version 24.

Results:

Gender distribution showed 48.2% were male and 51.8% were female. The mean age was 9.98 ± 3.5 years. Mean weight was 34.89 ± 18.2 kg. Mean BMD z-score was − 1.64 ± 1.4. Weight was considered to significantly correlate with BMD stature at a P = 0.014. Subjects who were underweight showed a lower mean BMD z-score of <−2 than those who were overweight/obese (mean BMD z-score = −1.60).

Conclusion:

Both extremes of weight are considered a significant risk factor for the development of low BMD in children. We recommend the early recognition of weight aberrations and consequent aggressive intervention with strict lifestyle modifications to promote the development of maximum peak bone mass.

Longitudinal changes in bone mineral density in children with inflammatory bowel diseases

AIM

Children with inflammatory bowel disease (IBD) are prone to low bone mineral density (BMD). Our aim was to assess longitudinal changes in BMD in this population.

METHODS

A retrospective longitudinal study of children with IBD, treated at two tertiary centres in Israel, who underwent two BMD measurements by dual-energy X-ray absorptiometry (DXA). Changes in lumbar spine BMD (∆L1-4 z-scores) were examined for correlations with clinical characteristics.

RESULTS

The cohort included 41 patients (age at diagnosis 12.1 ± 3.5 years, 23 females).The mean interval between the scans was 3.4 ± 2.0 years. There was a trend towards improvement in L1-4 z-scores (-1.64 ± 1.02 vs -1.45 ± 0.83, P = .12). ∆L1-4 z-scores correlated positively with ∆weight-standard deviation scores (SDS), ∆height-SDS and ∆BMI-SDS, and with age at the second scan (R = .55, P < .01; R = .42, P < .01; R = .42, P = .01; R = .35, P = .02, respectively); and negatively with L1-4 z-scores at the first scan (R = -.63, P < .01). Stepwise linear regression analysis identified the first scan L1-4 z-scores and ∆weight-SDS as independent predictors of ∆L1-4 z-scores. An L1-4 z-score ≤-2 at the first DXA scan was associated with significant improvement at the second scan.

CONCLUSION

Improvement in BMD was more pronounced in children who gained weight or whose BMD was low at the first scan.

Consumption of Cow's Milk in Early Childhood and Fracture Risk: A Prospective Cohort Study

Cow's milk is consumed by most North American children, yet the relationships between the volume and fat content of cow's milk consumed and childhood fracture risk are unclear. Our primary objectives in this study were to evaluate whether the volume or fat content of cow's milk consumed at 1-3 years of age was associated with the risk of fracture between 3 and 10 years of age. This was a prospective cohort study of 2,466 children enrolled in Toronto, Ontario, Canada, between 2008 and 2016. The primary exposure was volume of cow's milk consumed between the ages of 1 and 3 years, and the secondary exposure was average percentage of milk fat consumed by each child during the same period. The primary outcome was a parental report of child fracture at ages 3-10 years. In the primary and secondary adjusted analyses, no association between milk volume and fracture risk (adjusted relative risk = 1.04, 95% confidence interval: 0.87, 1.26) or between milk-fat content and fracture risk (adjusted relative risk = 1.05, 95% confidence interval: 0.84, 1.31) was observed. In this study, we did not identify a protective association of early childhood cow's milk volume or fat consumption with fracture risk in later childhood. Future prospective research is needed to understand whether cow's milk is beneficial for fracture prevention through the life course.

The Role of Obesity in Pediatric Orthopedics

Pediatric obesity has become a worldwide epidemic and leads to notable effects on the developing skeleton that can have lifelong implications. Obesity in the pediatric population alters bone metabolism, increasing the risk for fracture. It can alter the presentation of common pediatric orthopaedic conditions such as scoliosis. Obesity also leads to changes in the patterns and severity of pediatric fractures as well as alters conservative fracture treatment due to increased displacement risk. Obese pediatric trauma patients place a high burden on the nationwide hospital system in a variety of ways including the increased risk of perioperative complications. Obesity is modifiable, and addressing the issue can improve the orthopaedic and overall health of children.

Minodronate treatment improves low bone mass and reduces progressive thoracic scoliosis in a mouse model of adolescent idiopathic scoliosis

Recent studies have shown an association between osteopenia and adolescent idiopathic scoliosis (AIS) and implied that osteopenia plays a causative role in AIS development. This study aimed to determine if minodronate (MIN) treatment could prevent curve progression by increasing bone mass in a thoracic restraint (TR) mouse model, which develops causes the development of thoracic scoliosis similar to human AIS. A total of 100 young female C57BL6J mice were divided into four groups: (1) control with vehicle (CON/VEH; n = 20), (2) control with MIN (CON/MIN; n = 20), (3) TR with vehicle (TR/VEH; n = 30), or (4) TR with MIN (TR/MIN; n = 30). MIN (0.01 mg/kg/week) and vehicle were administered intraperitoneally to their respective groups. TR was performed at age 4 weeks, and the mice were sacrificed at age 9 weeks. Body weights, spine radiographs, femoral bone mineral density (BMD), serum bone marker levels, and histomorphometry of the cancellous bone of the thoracic vertebrae were analyzed. TR significantly reduced weight gain in the TR/VEH group relative to the CON/VEH group. TR also induced osteoporosis with accelerated bone resorption, as indicated by decreases in femoral BMDs and thoracic cancellous bone volume and increases in serum bone resorption marker levels and histomorphometric resorption parameters in the TR/VEH group. MIN partially improved body weight gain and improved poor bone structure relative to the TR/VEH group by suppressing high bone resorption in the TR/MIN mice. MIN significantly reduced the curve magnitudes, as indicated by a 43% lower curve magnitude in the TR/MIN mice than in the TR/VEH mice (17.9 ± 8.9° vs. 31.5 ± 13.1°; p< 0.001). The administration of MIN increased bone mass and reduced the severity of scoliosis in the TR mice. MIN was suggested as a possible inhibitor of scoliosis development.

Bone mineral density comparison of adolescents with constitutional thinness and anorexia nervosa

BACKGROUND

The negative impact of anorexia nervosa (AN) on bone health is well defined. However, there are very few studies evaluating the effect of constitutional thinness on bone health, especially in the adolescent period and in the male gender. The aim of this study is to compare the bone mineral density (BMD) measurements of adolescents with AN and with constitutional thinness.

METHODS

Between April 2013 and March 2014, 40 adolescents with AN and 36 adolescents with constitutional thinness participated in the study. The femoral neck and lumbar spine BMD were measured by dual energy X-ray absorptiometry (DXA).

RESULTS

Mean lumbar z and BMD scores of adolescents with constitutional thinness were significantly lower than in adolescents with AN, whereas the mean femoral z and BMD scores were not significantly different. When males were compared separately, lumbar z and BMD values of the constitutionally thin group were found to be significantly lower than in the AN group. This difference was not significant for females.

CONCLUSIONS

The difference between the male and female results of our study suggested two hypotheses. The significantly lower BMD values in constitutionally thin boys are attributed to their longer duration of low body mass index (BMI). Although the duration of low BMI is also longer for constitutionally thin girls, similar BMD values of AN and constitutionally thin female groups are attributed to the additional negative impact of estrogen deficiency on the bone health of girls with AN.

Comparison of body composition and adipokine levels between thin and normal-weight prepubertal children

OBJECTIVE

Thinness can have substantial consequences for child development and health. Adipokines, including leptin and adiponectin, play a significant role in the regulation of important metabolic functions. The aim of this study was to investigate associations between body composition and serum leptin and adiponectin levels in thin and normal-weight children.

METHODS

The authors examined 100 healthy prepubertal children, who were divided into two subgroups: thin (n=50) and normal-weight children (n=50). Body composition was assessed by dual-energy X-ray absorptiometry. Serum concentrations of adipokines were determined by immunoenzymatic assays.

RESULTS

Thin children had a similar body height but significantly lower (p<0.0001) body weight, body mass index, fat mass, lean mass, and bone mineral content compared with normal-weight children. Serum concentrations of leptin were about 2-fold lower (p<0.0001) in thin vs. normal-weight subjects. Serum levels of total adiponectin, adiponectin multimers, and soluble leptin receptor (sOB-R) were similar in both groups. The leptin/soluble leptin receptor ratio and leptin/adiponectin ratios were lower (p<0.0001) in thin vs. normal-weight children. In both groups of children, it was found that body composition parameters were positively related with leptin but not with adiponectin levels. Additionally, bone mineral content was positively related with body mass index, fat mass, lean mass, and leptin level in thin and normal-weight children.

CONCLUSIONS

Prepubertal thin children have disturbances in body composition and adipokine profile. Early recognition of thinness and determination of body composition parameters and adipokine levels can be useful in medical and nutritional care of thin children for the optimization of bone mineral accrual.

Pediatric-onset inflammatory bowel disease poses risk for low bone mineral density at early adulthood

BACKGROUND

Inflammatory bowel disease (IBD) is known to pose a risk for low bone mineral density (BMD) in children and adults. We aimed to evaluate the impact of pediatric-onset IBD on BMD in adulthood.

METHODS

Records of pediatric-IBD patients were retrospectively reviewed for documentation of dual-energy X-ray absorptiometry (DXA) scans in adulthood. BMD was expressed as z-score.

RESULTS

Sixty one patients were included. Mean (±SD) age at diagnosis was 14.7 (±2.4) years. Mean age at first DXA scan in adulthood was 23.9 years (±4.8). Median BMD z-score was -1.2 SD (IQR, -1.8 to -0.4), significantly lower than expected in normal population (p<0.001). Osteopenia (BMD z-score ≤-1 SD) was noted in 44.3% (n=27), and osteoporosis (BMD z-score ≤-2.5 SD) in 8.2% (n=5). Bone-status showed no correlation with age, disease severity, vitamin D status at diagnosis, IBD subtype or duration of disease. Positive correlation (r=0.306) was identified between low weight z-score at diagnosis and abnormal bone-status in adulthood. Among 36 patients with multiple DXA scans, there was no significant change in BMD during follow-up of 2.4 years.

CONCLUSIONS

Osteopenia and osteoporosis are frequent in adult IBD patients with pediatric-onset disease and correlates with low weight z-score at diagnosis.

Fracture risk and correlating factors of a pediatric population with attention deficit hyperactivity disorder: a nationwide matched study

The aim of this study was to investigate the risk of fracture and the difference between sexes from a nationwide database of fracture risk among children aged 4-17 years with or without attention deficit hyperactivity disorder (ADHD, ICD-9-CD codes 314). The Longitudinal Health Insurance Database (LHID 2000) was used to analyze fracture characteristics of children from the National Health Insurance that covered 96.1% of the Taiwanese population (N=21.4 million). A total of 7200 ADHD children aged between 4 and 17 years whose diagnosis had been confirmed in at least three outpatient clinics between 1 January 2000 and 31 December 2009 were included, and a cohort of 36 000 children without ADHD matched for age, sex, and urbanization was recruited for analysis. The incidence rate of fractures in ADHD children was 21.0 (95% confidence interval=19.4-22.7) per 1000 person-years, significantly (P<0.001) higher than 15.0 (95% confidence interval=14.4-15.6) in non-ADHDs. After adjusting by age, sex, urbanization level, and geographic region, the statistically significant (P<0.001) hazard ratios (HR) of fracture for ADHD children compared with non-ADHD children included 1.62 in girls and 1.38 in boys, 1.53 in the skull, neck, and trunk (ICD-9-CM 800-809), 1.28 in the upper extremity (ICD-9-CM 810-819), and 1.84 in the lower extremity (ICD-9-CM 820-829). The HR also (P<0.001) increased significantly in all age groups, including 1.35 in 4-6, 1.37 in 7-9, and 1.54 in 10-17 years. ADHD should be listed among risk factors of children's fractures in each sex, all age groups, and all body areas that the parents, teachers, caregivers of ADHD children, and pediatric orthopedists should be aware of. Besides, ADHD girls were more affected than ADHD boys, especially after 10 years of age, whereas the adjusted HR was the highest in the lower extremities. Nationwide analysis matched for age and sex showed that ADHD should be considered the risk factor of children's fracture, especially for girls older than 10 years of age.

The influence of underweight and obesity on the diagnosis and treatment of appendicitis in children

PURPOSE

The impact of lower body mass index (BMI) on appendicitis has never been addressed. We investigated whether different BMIs affect the diagnosis and treatment of appendicitis in children.

METHODS

The correlation between BMI and diagnosis accuracy and treatment quality was evaluated by retrospective analysis of 457 children diagnosed with appendicitis. Based on BMI percentiles, patients were classified as either underweight (n = 36), normal weight (n = 346), overweight (n = 59), or obese (n = 16). Diagnosis accuracy was measured by negative appendectomy rate, perforation rate, and number of consultations. Treatment quality was measured by complication rate and length of hospital stay.

RESULTS

Underweight patients had the highest negative appendectomy (OR 3.00, P = 0.008) and complication (OR 2.75, P = 0.041) rate. BMI did not influence perforation rate or number of consultations. Both underweight and obese patients stayed in the hospital longer than normal weight patients (regression coefficient 2.34, P = 0.001, and regression coefficient 9.40, P < 0.001, respectively). Furthermore, in obese patients, the hospital stay after open appendectomy was prolonged compared to laparoscopic appendectomy (P < 0.001). No such differences were observed in patients with lower BMI.

CONCLUSIONS

Underweight children are misdiagnosed more often, stay in hospital longer, and experience more postoperative complications than children of normal weight. Obesity is associated with longer hospital stays. Laparoscopic appendectomy might shorten the length of hospital stays in these patients. We conclude that in addition to obesity, underweight should also be considered a risk factor for children with appendicitis.

Spinal Bone Texture Assessed by Trabecular Bone Score in Adolescent Girls With Anorexia Nervosa

CONTEXT

Trabecular bone score (TBS) is a bone assessment tool that offers information beyond that afforded by dual-energy x-ray absorptiometry (DXA) bone mineral density (BMD) measurements. Adolescents with anorexia nervosa (AN) are known to exhibit compromised bone density and skeletal strength.

OBJECTIVES

This study aimed to determine TBS among adolescents with AN and evaluate the correlation with anthropometric, clinical and densitometric variables.

DESIGN

Areal BMD spinal measures were analyzed for TBS. Findings were compared with clinical (height, weight, body mass index [BMI], age, pubertal development, 25-hydroxyvitamin D) and self-reported data (illness duration, amenorrhea, exercise, fracture, family history of osteoporosis, and antidepressant use), and BMD measures by DXA and peripheral quantitative computed tomography (pQCT).

SETTING AND PARTICIPANTS

This was an urban adolescent program consisting of 57 females with AN, age 11-18 y.

INTERVENTIONS

Interventions included DXA (absolute BMD and Z-score), pQCT (volumetric BMD [vBMD] and stress-strain index [SSI]), laboratory evaluation, and questionnaire administration.

MAIN OUTCOME MEASURES

Main outcome measures included TBS, areal and vBMD, SSI, fracture history, disease duration.

RESULTS

The TBS of six participants (11%) showed degraded and 19 (33%) partially degraded microarchitecture. Spinal TBS was correlated (P < .05) with age, height, weight, BMI, pubertal stage, BMD, and body composition by DXA, and BMD and SSI by pQCT. TBS was not correlated with disease duration, fracture, vitamin D status, race, or ethnicity, and self-reported health data.

CONCLUSIONS

TBS showed evidence of degraded microarchitecture in over 40% of this study sample, and strongly correlated with anthropometric data and measures of BMD and skeletal strength. TBS is a novel tool that captures another dimension of bone health in adolescents with AN.