BMD testing unnecessary for children with repeat fractures

Although fractures may be on the rise in U.S. children, bone mineral density (BMD) tests are unnecessary for most children who experience repeat fractures. Recent research has shown a correlation between recurrent fractures during childhood and decreased BMD, but the safest and most accurate way to identify any concerns about a child’s BMD level is through regular physical exams and an assessment of the child’s dietary history, according to the presenters of Paper 507.

In healthy children, BMD increases with age and peaks in early adulthood. Reaching optimal peak bone mineral mass is the best way to prevent osteoporosis later in life. Children with low BMD have bones with less than optimal amounts of calcium and other minerals that make them strong. As a result, these children’s bones are more susceptible to fractures.

The research team conducted a study to determine if children with two or more incidences of fractures have low BMD. The team also investigated whether BMD testing is necessary for children with multiple incidences of bone fractures.

“Our findings show that children with several incidences of fractures do not require bone mineral density testing,” explained lead author John M. Mazur, MD. “Children who experience more than one fracture may indeed have decreased bone mineral density compared to other children their age, but certainly not enough to warrant additional x-ray testing or medical treatment.”

BMD is most accurately measured by DEXA (dual energy x-ray absorptiometry) scanning, which require the patient to lie down while the x-ray device passes over the spine, pelvic and hip area to assess bone strength and health.

Researchers reviewed DEXA scan results of 48 boys and 16 girls between the ages of 5 and 17 who experienced several fractures. They found these patients were more likely to have diminished BMD levels compared to peers in their same age and sex subset. However, only one of the 64 patients had BMD levels in what is considered the “osteoporotic” range.

Based on the study findings, DEXA scans should not be considered part of routine screening in children with frequent fractures. Instead, regular physical exams and an inventory of children’s dietary intake can provide physicians with the information needed to determine whether further treatment is required.

“Physician screening of young patients for calcium intake and bone health should occur three times during childhood: at age 2 or 3 after weaning from breast milk or formula, at 8 or 9 before the adolescent growth spurt, and during the puberty or teen years when the peak rate of bone mass growth occurs,” explained Dr. Mazur. “Screening should include asking young patients—and their parents—simple questions about diet, milk consumption, the amount of exercise, bone fractures and any family history of osteoporosis.”

While studies have shown the effectiveness of medications in treating adults with osteoporosis, the safety and effectiveness of these drugs in children remain largely unknown. Additionally, minimal research to date has focused on treating or preventing osteoporosis in children. What is known, however, is that poor nutrition—including a low calcium diet—low body weight and a sedentary lifestyle, beginning in childhood, are risk factors for osteoporosis.

Parents must also play a critical role in ensuring children adhere to bone-maximizing behaviors. Reinforcing the importance of a calcium and vitamin D-rich diet, coupled with regular daily exercise—especially during childhood and adolescence—are critical ways to promote bone health, according to Dr. Mazur.

Because osteoporosis is much easier to prevent than to treat, AAOS suggests the following tips for promoting overall good bone health in children:

The study was funded by the Nemours Clinical Management Program, the Nemours Foundation, Jacksonville, Fla. In addition to Dr. Mazur, co-authors include: Robert Olney, MD; Gabriela Ramirez-Garnica, PhD, MPH; Eric A. Loveless, MD; R. Jay Cummings, MD; David M. Mandel. MD; G. Alan Hahn, MD, and Kevin M. Neal, MD, all of Jacksonville, Fla.

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