Pediatric Osteoporosis Treatment & Management

Management is primarily medical, depending on the underlying condition. If the underlying condition is optimally managed and low bone density for age persists, then management depends on bone dynamics. Go to Osteoporosis and Nonoperative Treatment of Osteoporotic Compression Fractures for complete information on these topics.

When bone resorption exceeds bone formation, try an antiresorptive agent (eg, bisphosphonate;. currently, antiresorptives are the only consistently reliable antiosteoporosis medications.

The most current generation of oral bisphosphonates includes alendronate and risedronate. The primary parenterally administered bisphosphonate is pamidronate. Safe and effective pediatric doses have not been established; however, current clinical trials are investigating the use of alendronate in children with osteogenesis imperfecta, and preliminary results indicate that the drug is safe but not necessarily effective.

Pamidronate is currently under study in children with burn injuries. The dose of pamidronate is 1.5 mg/kg weekly for 2 weeks with a maximum dose at any one time of 90 mg, which is the adult upper limit of normal. In a 2-year follow-up study by Przkora et al evaluating changes in bone density and histology following the initial treatment with pamidronate, data supported a long-term effect on trabecular bone density and bone mineral content of the lumbar spine.^[22]

Total body bone mineral content (BMC) eventually showed recovery in patients with burn injuries on placebo therapy; therefore, the effect on cortical bone did not appear long lasting. Data obtained from clinical studies in adults are very promising. However, caution in the overuse of these drugs is warranted because the drugs remain in bone for a long time and an osteopetrosis-like condition has been reported.

Zoledronic acid is now under investigation, and preliminary data suggest it is equally effective as pamidronate in preventing bone loss.^[23]

Denosumab, the monoclonal antibody to receptor activator of nuclear transcription factor kappa B ligand (RANKL), can successfully prevent bone loss in adults with osteoporosis but to date has not been studied in children for safety or efficacy.

Anabolic steroids (eg, testosterone, oxandrolone) may be helpful in forming new bone; however, consider the risks of premature closure of the epiphyses, short stature, and hirsutism. Also consider the potentially increased risk for tumor development. However, in a 2004 study, oxandrolone was given for 1 year to a group of children following burn injury.^[24] No epiphyseal closure was demonstrated, and only 2 cases of clitoral hypertrophy were observed (both were reversed after cessation of the drug).

Recombinant human growth hormone is a useful anabolic agent for children with growth hormone deficiency; its benefits for others with low bone density for age have not been extensively studied. It does improve BMC in burned children if given for a year, but the need for repeated injections and the cost are limiting.^[25]

The absence of a safe and effective anabolic agent makes bone loss secondary to low bone formation more difficult to manage than bone loss secondary to high bone resorption. Parathyroid hormone (PTH), which is potentially very promising when given intermittently to osteoporotic adults, is not approved for use in children because of the detection of osteogenic sarcoma in mice that were given very high test doses.^[26]

Unless a resectable tumor can be identified as the cause of low bone density for age or osteoporosis, surgery is unlikely to play a role in treatment. In most cases, the cause is systemic and results in widespread disease.

Calcium and vitamin D are the most important dietary nutrients to help prevent adult osteoporosis, although a recent study suggests that calcium supplementation does not promote a significant accumulation in the appendicular skeleton.^[27] A diet rich in dairy products is recommended to help provide the calcium and vitamin D required.

The NIH Consensus Conference on Osteoporosis recommended a calcium intake of 800 mg/d until age 10 years, 1200 mg/d during adolescence, and 1000 mg/d after adolescence.^[1] Calcium intake should be increased for women who are pregnant, for women who are lactating (1200 mg/d), and for individuals older than 65 years (1500 mg/d).

An intake of vitamin D of 400-800 international U/d is also recommended, but optimal amounts are still debated, and the vitamin D requirements of the body in different disease states is still unknown.^[28]

Note the Institute of Medicine 2010 dietary criteria at DRIs for Calcium and Vitamin D.

Activity plays a role in the prevention of osteoporotic fractures. Several recent studies in the United States and in Europe have established that regular weight-bearing exercise, such as jumping, in school-aged children improves bone mass.^[29]

Experts in osteoporosis may come from several subspecialties. Traditionally, osteoporosis is the province of the pediatric endocrinologist, but experts may be found in pediatric nephrology, gastroenterology, or orthopedic surgery as well.

Generally, individuals suffering from bone loss alone (formerly termed osteoporosis) do not require hospitalization unless they have a complication such as a hip fracture. This is a very uncommon occurrence in children; however, following a fracture, anticipatory intervention is needed to minimize future hospital stays and to identify individuals at risk for repeated fractures.

The aim of further outpatient care is to closely monitor bone density to determine if ongoing bone loss occurs or if the process has reached a plateau. The AAP recommendation for repeating bone densitometry testing is that, although 6 months should normally elapse between measurements, it might be appropriate in some cases to wait at least 1 year.^[20] In situations of ongoing bone loss, measurements of biochemical markers of bone formation and resorption can help guide management.

Transferring a patient is not necessary unless pediatric subspecialty care is unavailable at the institution.