Osteoporosis in Children: Implications for Nursing

Abstract

Osteoporosis affects children worldwide. These children are at increased risk of fractures from activities of daily living and may be restricted in their play secondary to this. Parents live in fear of causing a fracture during routine activities, and they worry about their children's future bone health. As nurses, we can make a difference at many levels in the lives of these children, their families, and other caregivers. We first need to understand what osteoporosis is, potential prevention strategies, and risk factors. We can then help to identify the child at high risk, educate them and their family, and be a resource for other caregivers and health professionals who are less familiar with childhood osteoporosis. From prevention to diagnosis, treatment and safe handling practices, pediatric nurses can have a positive influence in the lives of all children and families. In emergency rooms, operating rooms, patient care units, clinics and within the home, schools, or communities, nurses with knowledge of osteoporosis will impact the life of a child living with this often debilitating condition in many positive ways. Bones start to accumulate mass during intrauterine life and continue into the fourth decade of life. Peak bone mass is usually achieved during late adolescence and serves as the bulk of bone mass for life (Bachrach, 2007Bachrach L. Consensus and controversy regarding osteoporosis in the pediatric population.Endocrine Practice. 2007; 13: 213-520Crossref Scopus (45) Google Scholar, Cooper et al., 2008Cooper C. Harvey N. Javaid K. Hanson M. Dennison E. Growth and bone development.Nestle Nutrition Workshop Scr Pediatric Program. 2008; 61: 53-68Crossref PubMed Scopus (2) Google Scholar). Osteoporosis is defined as a disease of brittle or porous bone leading to an increased fracture risk. For children, osteoporosis can develop without any identifiable cause (idiopathic), or it develops as a result of certain medical conditions, medications, mobility issues, dietary deficiencies, or hormonal imbalances alone or in combination (secondary osteoporosis; National Institutes of Health Osteoporosis and Related Bone Diseases, 2009National Institutes of Health Osteoporosis and Related Bone Diseases Juvenile osteoporosis.National Resource Centre. 2009; (Retrieved from)www.niams.nih.gov/boneGoogle Scholar). Many factors can put a child at risk for osteoporosis. A compilation of the most common factors are listed in Table 1 (Baroncelli et al., 2005Baroncelli G. Bertelloni S. Sodini F. Saggese G. Osteoporosis in children and adolescents: Etiology and management. Review Article.Pediatric Drugs. 2005; 7: 295-323Crossref PubMed Scopus (83) Google Scholar, Brown & Zacharin, 2005Brown J.J. Zacharin M.R. 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Review article.Paediatric Respiratory Reviews. 2009; 10: 134-142Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar).Table 1Factors That Place Children at High Risk for OsteoporosisMedical ConditionsAnorexia nervosaCancer/LeukemiaCerebral palsyChronic kidney diseaseCystic fibrosisDiabetesHyperparathyroidismHyperthyroidismInflammatory bowel diseaseMalabsorption syndromesMuscular dystrophy or other neuromuscular conditionsOIPost-organ transplantProlonged amenorrheaRheumatic diseasesBehaviorsMedicationsA diet very high in phosphates with very low calcium/vitamin D intakeAnticonvulsantsLow calcium and vitamin D intakeCorticosteroids for less than 3 monthsProlonged inactivity or immobilityImmunosuppressant treatmentSmoking and alcohol abuse Open table in a new tab Osteoporosis has often been called the “silent thief” because it results from clinically silent loss of bone mass (Osteoporosis, 2008Osteoporosis Canada Diagnosis: how strong are your bones?. Toronto, Ontario, Canada: Osteoporosis Canada, 2008Google Scholar). The diagnosis of osteoporosis in children is different than in adults. For adults, a dual energy x-ray absorptiometry (DXA) or bone mineral densitometry (BMD) test with a t-score less than −2.5 standard deviations from the mean indicates osteoporosis. For children, it is more complex. DXA scans can be performed on children, but t-score measures are not reported. Instead, a BMD z-score utilizing standardized bone density with respect to age, gender, bone age, height, and weight is needed (Baroncelli et al., 2005Baroncelli G. Bertelloni S. Sodini F. Saggese G. Osteoporosis in children and adolescents: Etiology and management. Review Article.Pediatric Drugs. 2005; 7: 295-323Crossref PubMed Scopus (83) Google Scholar, Gordon et al., 2008Gordon C. Bachrach L. Carpenter T. Crabtree N. Fuleihan G. Kutilek S. et al.Dual energy x-ray absorptiometry interpretation and reporting in children and adolescents: The 2007 ISCD pediatric official positions.Journal of Clinical Densitometry: Assessment of Skeletal Health. 2008; 11: 43-58Abstract Full Text Full Text PDF PubMed Scopus (296) Google Scholar, Kalkwarf et al., 2007Kalkwarf H. Zemel B. Gilsanz V. Lappe J. Horlick M. Oberfield S. et al.The bone mineral density in childhood study: Bone mineral content and density according to age, sex and race.Journal of Clinical Endocrinology and Metabolism. 2007; 92: 2087-2099Crossref PubMed Scopus (297) Google Scholar). For children, a DXA scan with an areal or two-dimensional BMD z-score of less than −2.0 SD plus a recent history of fractures from standing height or less (nontraumatic) is diagnostic of osteoporosis. These fractures are defined as either a long-bone fracture of the lower extremity, a vertebral compression fracture, or two or more long-bone fractures of the upper extremities (Gordon et al., 2008Gordon C. Bachrach L. Carpenter T. Crabtree N. Fuleihan G. Kutilek S. et al.Dual energy x-ray absorptiometry interpretation and reporting in children and adolescents: The 2007 ISCD pediatric official positions.Journal of Clinical Densitometry: Assessment of Skeletal Health. 2008; 11: 43-58Abstract Full Text Full Text PDF PubMed Scopus (296) Google Scholar). It is important when ordering a DXA scan in a child to include the following: child's age, gender, ethnicity, height, weight, bone age, body composition, pubertal status, and relevant medical history including prior fractures to allow for the best interpretation (Gordon et al., 2008Gordon C. Bachrach L. Carpenter T. Crabtree N. Fuleihan G. Kutilek S. et al.Dual energy x-ray absorptiometry interpretation and reporting in children and adolescents: The 2007 ISCD pediatric official positions.Journal of Clinical Densitometry: Assessment of Skeletal Health. 2008; 11: 43-58Abstract Full Text Full Text PDF PubMed Scopus (296) Google Scholar). For children younger than 4 years, comparative normal values for DXA scanning are lacking. Many practitioners do not know that spinal compression fractures can be asymptomatic. Halton et al., 2009Halton J. Gaboury I. Grant R. Alos N. Cummings E. Matzinger M. et al.Advanced vertebral fracture among newly diagnosed children with acute lymphoblastic leukemia: results of the Canadian Steroid-associated Osteoporosis in the Pediatric Population (STOPP) Research Program.Journal of Bone and Mineral Research. 2009; 24: 1326-1334Crossref PubMed Scopus (150) Google Scholar reported on the increasing prevalence of spinal compression fractures in children with acute lymphoblastic leukemia during their research of the Canadian Steroid-associated Osteoporosis in the Pediatric Population (STOPP) Research Program. Often, a child can be identified as high risk for osteoporosis in the absence of one of the clear diagnostic criteria based on fracture history and the number of risk factors present. In this circumstance, the focus should be on prevention. Nurses can play a key role in the prevention efforts through education for the parents, child, and community. Ensuring women of childbearing age, infants, and children receive the recommended minimum dietary intake of calcium and vitamin D is the first place to start. Cooper et al., 2008Cooper C. Harvey N. Javaid K. Hanson M. Dennison E. Growth and bone development.Nestle Nutrition Workshop Scr Pediatric Program. 2008; 61: 53-68Crossref PubMed Scopus (2) Google Scholar reviewed the intrauterine and postnatal influences on bone growth, density, and mineral accrual. They emphasize the need for optimal maternal nutrition, lifestyle choices, and attention to newborn nutrition to help lower the risk of osteoporosis. The Dietary Reference Intakes (DRI) for calcium and vitamin D in children were changed in 2010 (Table 2). A one-cup serving of milk or most fortified beverages like rice or soy beverages contains approximately 300 mg of calcium and 100 IU of vitamin D (ensure to read the labels carefully). Many schools now have a milk program where parents can prepay for their child to have a milk serving at lunch. Some schools have even worked on a campaign toward educating students in a fun way, such as the “Sip and Skip” program, which encourages calcium and vitamin D intake plus physical activity to build healthy bones (Manitoba Dairy Farmers, 2011Manitoba Dairy Farmers School programs.www.milk.mb.caDate: 2011Google Scholar). A dietician can help a family assess their child's dietary intake of calcium, vitamin D, and phosphate and assist with recommendations for improving bone health.Table 2DRI for Calcium and Vitamin DAgeCalcium, mg/dayVitamin D, IU/day0–6 months2004006–12 months2604001–3 years7006004–8 years1,0006009–18 years1,300600Note: Data from Institute of Medicine, 2010Institute of Medicine Dietary reference intakes for calcium and vitamin D; Consensus report.http://www.iom.edu/Reports/2010/Dietary-Reference-Intakes-for-Calcium-and-Vitamin-D.aspxDate: 2010Google Scholar. Open table in a new tab Note: Data from Institute of Medicine, 2010Institute of Medicine Dietary reference intakes for calcium and vitamin D; Consensus report.http://www.iom.edu/Reports/2010/Dietary-Reference-Intakes-for-Calcium-and-Vitamin-D.aspxDate: 2010Google Scholar. It is difficult to meet the DRI of vitamin D through diet alone. Vitamin D supplements are available over the counter in measures of 400 or 1,000 IU in both tablets and drops. There are times where oral supplements of vitamin D prescribed by a health care professional are needed to maintain a serum 25-hydroxyvitamin D or 25(OH)D level greater than 75 nmol/L (Kirouac et al., 2010Kirouac N. Miller K. Stocki A. Rempel G. Taback S. Gies J. et al.Childhood osteoporosis: Screening, prevention, treatment and safe handling practices: A child health project, Canadian Association for Pediatric Health Professionals Conference, Poster presentation. October 20102010Google Scholar). Vitamin D supplementation is especially important if living at higher latitudes, if there is poor dietary vitamin D intake, and in those with darker skin pigment because vitamin D synthesis is less efficient in darker skinned people (Mithal et al., 2009Mithal A. Dawson-Hughes B. Eisman J. Fuleihan G. Josse R. Lips P. et al.on behalf of the International Osteoporosis Foundation Committee of Scientific Advisors (CSA) Nutrition Working GroupGlobal vitamin D status and determinants of hypovitaminosis D.Osteoporosis Int. 2009; 20: 1807-1820Crossref PubMed Scopus (1093) Google Scholar, Langlois et al., 2010Langlois K. Greene-Finestone L. Little J. Hidirogloui N. Whiting S. Vitamin D status for Canadians as measured in the 2007 to 2009 Canadian health measures survey. Statistics Canada, Catalogue no 82-003-XPE.Health Reports. 2010; 21: 47-55Google Scholar). Mithal et al., 2009Mithal A. Dawson-Hughes B. Eisman J. Fuleihan G. Josse R. Lips P. et al.on behalf of the International Osteoporosis Foundation Committee of Scientific Advisors (CSA) Nutrition Working GroupGlobal vitamin D status and determinants of hypovitaminosis D.Osteoporosis Int. 2009; 20: 1807-1820Crossref PubMed Scopus (1093) Google Scholar reviewed the global vitamin D status in six regions of the world and concluded that there is widespread hypovitaminosis D in almost all regions. In a similar study reported by Langlois et al., 2010Langlois K. Greene-Finestone L. Little J. Hidirogloui N. Whiting S. Vitamin D status for Canadians as measured in the 2007 to 2009 Canadian health measures survey. Statistics Canada, Catalogue no 82-003-XPE.Health Reports. 2010; 21: 47-55Google Scholar describing the vitamin D status of Canadians, they found that from the nationally representative sample, only 35% of those aged 6–79 are above the cutoff of 75 nmol/L 25(OH)D. Low milk consumption and non-White racial background were key risk factors for vitamin D deficiency. The recommendations for vitamin D supplementation for aboriginal newborns from northern communities who are breastfed have been 800 IU/day because of the increased incidence of vitamin D deficiency leading to hypocalcemic seizures in this population (P. Ozechowsky, personal communication, October 28, 2010). The U.S., 2004U.S. Department of Health and Human Services The 2004 Surgeon General's report on bone health and osteoporosis: What it means to you. U.S. Department of Health and Human Services, Office of the Surgeon General, Washington, DC, 2004Google Scholar published a report on bone health and osteoporosis indicating how poor bone health is common and costly because of fractures, hospitalizations, and increased doctor visits. This reinforces the importance of early prevention efforts to decrease the incidence of osteoporosis and to prevent the complications of this disease on individuals and their associated cost to society. In addition to adequate dietary calcium and vitamin D, lifestyle choices can help prevent osteoporosis. Daily weight-bearing physical activity, avoidance of smoking, and decreasing soft-drink consumption are a few modifiable risk factors (Osteoporosis, 2008Osteoporosis Canada, Manitoba Chapter Adolescent bones: The time to build is now!. Winnipeg, Manitoba, Canada: Osteoporosis Canada, 2008Google Scholar). Nurses can help educate children and their families through encounters in hospital units, in clinics, in schools, and in the community. In January 2011, the Government of Canada announced its support for the new Canadian Physical Activity Guidelines from the Canadian Society for Exercise Physiology (Public Health Agency of, 2011Public Health Agency of Canada News release. January 24, 2011. Government of Canada supports new physical activity guidelines. Ottowa, Canada: Public Health Agency of Canada, 2011www.publichealth.gc.caGoogle Scholar). These guidelines recommend that children and youth ages 5 to 17 years require at least 60 minutes a day of moderate to vigorous intensity physical activity, and adults require at least 150 minutes per week (Canadian Society for Exercise Physiology, 2011Canadian Society for Exercise PhysiologyClinical practice guidelines for physical activity: Complete report.www.csep.caDate: 2011Google Scholar). Children benefit in many ways from increasing their physical activity, with only some of those benefits being stronger bones and healthier muscles. Tips for helping children increase their physical activity can be found at the Public Health Agency of Canada Web site listed in Table 3. The National Institutes of Health (NIH) has an Osteoporosis and Related Bone Diseases National Resource Centre that now publishes booklets for parents and caregivers specifically on Juvenile Osteoporosis and Children's Bone Health, see Table 3 (National Institutes of Health Osteoporosis and Related Bone Diseases, 2009National Institutes of Health Osteoporosis and Related Bone Diseases Juvenile osteoporosis.National Resource Centre. 2009; (Retrieved from)www.niams.nih.gov/boneGoogle Scholar).Table 3Web sites for Nurses/FamiliesCanadian Physical Activity Guidelines @ www.phac-aspc.gc.caDRI @ www.iom.edu/Reports/2010/Dietary-Reference-Intakes-for-Calcium-and-Vitamin-D.aspxInternational Osteoporosis Foundation @ www.iofbonehealth.orgInternational Society for Clinical Densitometry Guidelines @ www.iscd.orgNational Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institute of Health @ www.niams.nih.govNational Osteoporosis Foundation @ www.nof.orgOffice of Women’s Health @ www.bestbonesforever.govOsteogenesis Imperfecta Foundation @ www.oif.orgOsteoporosis Canada @ www.osteoporosis.caU.S. Surgeon General's Report @ www.surgeongeneral.gov/library/bonehealth/content.htmlDairy Farmers of Manitoba @ www.milk.mb.ca Open table in a new tab One resource to share with patients is the “Best Bones Forever” (BBF) campaign, which targets young girls and encourages them to take advantage of the opportunity to accumulate bone mass in their youth when developing strong bones is most critical (Office of Women's, 2011Office of Women's Health, U.S. Health and Human Services Best bones forever. U.S. Health and Human Service.www.bestbonesforever.govDate: 2011Google Scholar). The National Osteoporosis Foundation has recently partnered with the BBF group in their fight to prevent osteoporosis, and they are recommending the BBF Web site to their viewers (National Osteoporosis Foundation, 2011National Osteoporosis Foundation When kids get osteoporosis & teen girls: Build strong bones now.National Osteoporosis Foundation. 2011; (Retrieved from)www.nof.orgGoogle Scholar). The same DRI guidelines for calcium and vitamin D apply to children with osteoporosis as listed in Table 2. Attention must be paid to ensure that the serum 25(OH)D levels drawn in the winter months be equal or greater than 75 nmol/L because of the increased risk of fractures in the high-risk child and the lack of available sunlight for vitamin D synthesis at that time (Kirouac et al., 2010Kirouac N. Miller K. Stocki A. Rempel G. Taback S. Gies J. et al.Childhood osteoporosis: Screening, prevention, treatment and safe handling practices: A child health project, Canadian Association for Pediatric Health Professionals Conference, Poster presentation. October 20102010Google Scholar). Medications called bisphosphonates slow down the cells that break down old bone, giving time for new bone to form. These have been used successfully to treat adult osteoporosis and relieve pain in children with osteogenesis imperfecta (OI). Although some clinicians have used bisphosphonates for children with osteoporosis, formal studies are needed in this population (Ward et al., 2007Ward L. Tricco A. Phuong P.N. Cranney A. Barrowman N. Gaboury I. et al.Bisphosphonate therapy for children and adolescents with secondary osteoporosis.Cochrane Database of Systematic Reviews. 2007; Google Scholar, Bachrach & Ward, 2009Bachrach L. Ward L. Clinical review: Bisphosphonate use in childhood osteoporosis.Journal of Clinical Endocrinology Metabolism. 2009; 94: 400-409Crossref PubMed Scopus (187) Google Scholar). Ward et al., 2007Ward L. Tricco A. Phuong P.N. Cranney A. Barrowman N. Gaboury I. et al.Bisphosphonate therapy for children and adolescents with secondary osteoporosis.Cochrane Database of Systematic Reviews. 2007; Google Scholar concluded in their Cochrane Review that further evaluation of bisphosphonate use in children with secondary osteoporosis was needed because current evidence does not support this as standard therapy. Safe handling of children diagnosed with osteoporosis is critical to prevent fractures. Nurses should work closely with an occupational therapist (OT) and physiotherapist (PT) to ensure that a specific care plan is developed that is reflective of the child's fracture risk and outlines management strategies. Educating parents to advocate on behalf of their child in the school and community to ensure safe play and help with daily activities as needed is an important nursing role in collaboration with OTs and PTs. The Osteogenesis Imperfecta Foundation provides educational booklets for families and other care providers to help prevent fractures in this population (Osteogenesis Imperfecta Foundation, 2011Osteogenesis Imperfecta Foundation www.oif.orgDate: 2011Google Scholar). These resources are also relevant for the child with osteoporosis who is at risk for fractures and can help provide a foundation for the development of future resources for this group. The interprofessional Pediatric Bone Health Committee at the Health Sciences Centre Children's Hospital in Winnipeg, Manitoba, Canada, has developed an inpatient algorithm to guide caregivers in recognizing the child at risk for osteoporosis. This algorithm includes a screening tool with recommendations for testing, diagnosis, and management (Kirouac et al., 2010Kirouac N. Miller K. Stocki A. Rempel G. Taback S. Gies J. et al.Childhood osteoporosis: Screening, prevention, treatment and safe handling practices: A child health project, Canadian Association for Pediatric Health Professionals Conference, Poster presentation. October 20102010Google Scholar). They discuss how the use of a new mascot called “Ostey” the dinosaur, with signage stating “Fragile: Handle with Care,” could become a universal symbol within the hospital and extend into the community to help others easily identify a child at risk for fractures due to osteoporosis. Uses of rubber stamps on requisitions, stickers on charts, and posters at the bedside with Ostey in the center have started that communication across the inpatient setting. A family and caregiver booklet was also developed as part of this initiative specifically for the child identified as high risk for fractures, containing information on osteoporosis, calcium and vitamin D, and safe play and special handling to prevent fractures (Kirouac et al., 2010Kirouac N. Miller K. Stocki A. Rempel G. Taback S. Gies J. et al.Childhood osteoporosis: Screening, prevention, treatment and safe handling practices: A child health project, Canadian Association for Pediatric Health Professionals Conference, Poster presentation. October 20102010Google Scholar). An interprofessional team approach with nutritionists, OTs, PTs, physicians, and nurses is recommended for the successful implementation of a care plan from diagnosis through treatment for children with osteoporosis (Kirouac et al., 2010Kirouac N. Miller K. Stocki A. Rempel G. Taback S. Gies J. et al.Childhood osteoporosis: Screening, prevention, treatment and safe handling practices: A child health project, Canadian Association for Pediatric Health Professionals Conference, Poster presentation. October 20102010Google Scholar, National Coalition for Osteoporosis and Related Bone Diseases, 2008National Coalition for Osteoporosis and Related Bone Diseases National action plan for bone health: Recommendations from the summit for a national action plan for bone health.www.oif.orgDate: 2008Google Scholar). Nurses have the opportunity to be leaders in this area by educating families and other health care workers about the reality of childhood osteoporosis. Poor bone health is emerging as an important threat to the health and lives of children and their families and needs attention from the emergency room through to the community, home, and school. Nurses now have many opportunities along the care continuum to impact this bone health system and the whole child in a positive way.