Healthy Children With Frequent Fractures: How Much Evaluation Is Needed?

Olney, Robert C.; Mazur, John M.; Pike, Leah M; Froyen, Melanie K; Ramírez-Garnica, Gabriela; Loveless, Eric A.; Mandel, David; Hahn, Gerhard; Neal, Kevin M.; Cummings, R. Jay

doi:10.1542/peds.2007-2079

Cited by 32 publications

(19 citation statements)

References 27 publications

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“…The fracture-prone children more often had hypercalciuria and hyperphosphaturia than the controls, despite lower dietary calcium intake in the patients. Hypercalciuria has been reported to associate with lower BMD in children (26,38,39) ; however, our 7 patients with hypercalciuria did not have lower BMD Z-scores than the other patients. Hyperphosphaturia may be caused by high PTH or signify inappropriate renal phosphate loss, especially when associated with low serum phosphate.…”

Section: Discussioncontrasting

confidence: 73%

“…(18,26,45) Interpretation of DXA in growing children has many pitfalls, and no guidelines exist as to when children with fractures should be screened with DXA. Furthermore, it remains unknown what other screening tools should be applied.…”

Section: Discussionmentioning

confidence: 99%

“…In a cohort of children with frequent fractures, low BMD was found in only 4% and reduced BMD was associated with hypercalciuria. (26) The aim of this study was to examine characteristics of apparently healthy children with frequent fractures, to identify potential risk factors, and to evaluate the prevalence of compromised overall bone health. In a pediatric university hospital setting, we prospectively evaluated all fracture patients for fracture history.…”

Section: J Jbmrmentioning

confidence: 99%

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Impaired bone health and asymptomatic vertebral compressions in fracture-prone children: A case-control study

Mäyränpää

Viljakainen

Toiviainen-Salo

et al. 2012

Journal of Bone and Mineral Research

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Frequent fractures in children may be a sign of impaired bone health, but it remains unestablished when and how fracture‐prone children should be assessed. This prospective study elucidated skeletal characteristics and predisposing factors in children with recurrent fractures. Findings were used to establish guidelines for screening. During a 12‐month period we recorded fracture history for all children (n = 1412) treated for an acute fracture at a large university hospital. All apparently healthy children over 4 years of age, who had sustained: (1) at least one vertebral fracture; (2) two long‐bone fractures before age 10 years; or (3) three long‐bone fractures before age 16 years, were recruited. They underwent dual‐energy X‐ray absorptiometry (DXA), laboratory tests, and spinal radiography. Information regarding family history and lifestyle factors were collected. Findings were compared with healthy controls. Sixty‐six fracture‐prone children (44 males, mean age 10.7 years; 5% of all children with fractures) were identified. Altogether, they had sustained 183 long‐bone fractures (median 3, range 0–7); 11 children had sustained vertebral fracture(s). Patients had significantly lower bone mineral density (BMD) at lumbar spine (p < 0.001), hip (p = 0.007), and whole body (p < 0.001) than the controls; only 5 children (8%) had a BMD Z‐score < −2.0. Asymptomatic vertebral compressions were prevalent, especially in those under 10 years of age. Hypercalciuria (11%) and hyperphosphaturia (22%) were significantly more prevalent than in controls. Serum concentration of 25‐hydroxyvitamin D (S‐25OHD) was below 50 nmol/L in 55%; low levels were associated with low BMD and vertebral compressions. The fracture‐prone children had lower calcium intake, less physical activity, and more often had siblings with fractures than the controls. The findings suggest that a thorough pediatric evaluation, including DXA and spinal radiography, is often indicated already after a second significant low‐energy fracture in children, in order to detect potentially preventable adverse lifestyle factors and nutritional deficits and to identify those with compromised overall bone health. © 2012 American Society for Bone and Mineral Research.

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Section: Discussioncontrasting

confidence: 73%

Section: Discussionmentioning

confidence: 99%

Section: J Jbmrmentioning

confidence: 99%

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Impaired bone health and asymptomatic vertebral compressions in fracture-prone children: A case-control study

Mäyränpää

Viljakainen

Toiviainen-Salo

et al. 2012

Journal of Bone and Mineral Research

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“…Increased adiposity is a recognised independent risk factor for both childhood fracture [9] and lower 25(OH)D status [15]. Thus, in the study of obese children, differences in BMI and age between vitamin D deficient and replete children should be considered in the interpretation of the documented findings [68].…”

Section: Fracture In Non-rachictic Childrenmentioning

confidence: 99%

Vitamin D and skeletal health in infancy and childhood

et al. 2014

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During growth, severe vitamin D deficiency in childhood can result in symptomatic hypocalcaemia and rickets. Despite the suggestion from some studies of a secular increase in the incidence of rickets, this observation may be driven more by changes in population demographics than a true alteration to age, sex and ethnicity-specific incidence rates; indeed rickets remains uncommon overall and is rarely seen in fair-skinned children. Additionally, the impact of less severe vitamin D deficiency and insufficiency has received much interest in recent years, and in this review we consider the evidence relating vitamin D status to fracture risk and bone mineral density (BMD) in childhood and adolescence. We conclude that there is insufficient evidence to support the suggestion that low serum 25-hydroxyvitamin D [25(OH)D] increases childhood fracture risk. Overall, the relationship between 25(OH)D and BMD is inconsistent across studies and across skeletal sites within the same study; however there is evidence to suggest that vitamin D supplementation in children with the lowest levels of 25(OH)D might improve BMD. High quality randomised trials are now required to confirm this benefit.

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“…In this study, BMC and BMD were associated inversely with urinary calcium loss, the primary marker of bone mineral status, and tended to be associated indirectly with ionized calcium concentrations in the RTT cohort. This observation is relevant because hypercalcuria has been associated with a history of fractures in healthy children (25). We did not demonstrate an association between PTH and BMC, BMD, or C-telopeptide, even though PTH is the primary hormonal mediator of bone resorption.…”

Section: Discussionmentioning

confidence: 99%

Low Bone Mineral Mass Is Associated With Decreased Bone Formation and Diet in Girls With Rett Syndrome

Motil

Barrish²,

Neul³

et al. 2014

J. pediatr. gastroenterol. nutr.

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Objective To characterize biomarkers of bone turnover and their relation with bone mineral mass in a cross-sectional cohort of females with Rett syndrome (RTT) and to examine the role of dietary, biochemical, hormonal, and inflammatory factors on bone mineral mass and bone biomarkers in this disorder. Methods Total body bone mineral content (BMC) and density (BMD) were determined by dual-energy x-ray absorptiometry. Dietary nutrient intakes were determined from 3-day food records. Biomarkers of bone turnover, bone metabolites, vitamin D metabolites, hormones, and inflammatory markers were measured by standard clinical laboratory methods. Results Serum osteocalcin, bone alkaline phosphatase, and C-telopeptide showed significant inverse relations with age in the RTT cohort. Mean osteocalcin concentrations were significantly lower and mean bone alkaline phosphatase concentrations were significantly higher for individual age groups in the RTT cohort than mean values for their respective age ranges in the reference population. Significant inverse associations were identified between urinary calcium losses, expressed as calcium:creatinine ratios, and total body BMC and BMD z-scores. Dietary protein, calcium, and phosphorus intakes, expressed as a proportion of Dietary Reference Intakes for age and gender, showed significant positive associations with total body BMD z-scores. Conclusion This study suggests decreased bone formation rather than increased bone resorption may explain in part the deficits in bone mineral mass in RTT and that attention to the adequacy of dietary protein, calcium and phosphorus intakes may offer an opportunity to improve bone health in RTT.

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Healthy Children With Frequent Fractures: How Much Evaluation Is Needed?

Cited by 32 publications

References 27 publications

Impaired bone health and asymptomatic vertebral compressions in fracture-prone children: A case-control study

Impaired bone health and asymptomatic vertebral compressions in fracture-prone children: A case-control study

Vitamin D and skeletal health in infancy and childhood

Low Bone Mineral Mass Is Associated With Decreased Bone Formation and Diet in Girls With Rett Syndrome

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