Pediatric osteoporosis definition, diagnosis, work up, common mistakes, approach to treatment, approved drugs in children and doses, different guidelines for pediatric osteoporosis

1. The challenge, pediatric
osteoporosis highlights
Ahmed Yehia, MD
Immunology, rheumatology & allergy
Beni-Suef

2. Whom to screen?
•Doctor, I want to be assured
about my child’s bone strength.

3. The Working Group of Osteogenesis
Imperfecta and Childhood
Osteoporosis of the Spanish Society of
Pediatric Rheumatology (SERPE, by its
Spanish acronym) recommendations

4. There is a need to monitor BMD in patients with chronic
diseases, especially those of endocrinologic, nutritional,
rheumatological, renal, metabolic, hematological,
neurological & gastrointestinal origin. (4 D 95%)
Special attention must be paid to patients with chronic
diseases who receive treatments that contribute to OP
development; e.g., GCs, chemotherapy treatments or
antiepileptic drugs. (2b B)

5. How to
screen?
X ray
Quantitative ultrasound
Quantitative CT
DXA scan
MRI
Bone turnover labs
Bone biopsy

6. AAP
•The American Academy of
Pediatrics recommends DXA
for children with clinically
significant fractures & those
with medical conditions that
place them at increased risk
for fractures.

7. AAP
• Although screening
questions & counselling to
prevent modifiable causes of
osteoporosis are appropriate
in all children, DXA is not
indicated in otherwise
healthy children.

8. • Since low bone mass has been associated
with increased fracture risk, DXA is the most
recommended method for pediatric
populations in order to assess bone health.
However, it does not allow for a prediction of
fracture risk. (2a B)

9. •A 7-year old girl with chronic
kidney disease was planned to
screen for osteoporosis.

12. 1
16. DXA of the lumbar
spine & total body less
head (TBLH) is the
chosen method to
measure BMD in
pediatrics, since they
are the most accurate &
reproducible areas of
the skeletal system for
this measurement. (2a B)
2
17. Data analyses
must be carried out
using pediatric
software (software
for adults
overestimates
BMD). (2b B)
3
18. Vertebrae DXA
measurement is
recommended for
children under the
age of 5 due to its
higher reproducibility &
shorter time necessary
for conducting this test.
(2a B)
4
19. For children under
the age of 3, total body
BMD is not
recommended on a
routine basis due to its
lack of reproducibility
in such young children;
rather BMC should be
used. (3a C)

13. Z-score -3

14. According to the International Society for Clinical
Densitometry (ISCD), pediatric osteoporosis is currently
defined by
the combination
of a bone mineral
density (BMD) Z-
score≤−2
a clinically
signifcant fracture
history
She is not defined as osteoporotic.

15. 3 months later, she came with radius
fracture.
two or more long bone
fractures before the age
of 10 years
or three or more long
bone fractures at any
age up to 19 years
She is not defined as
osteoporotic.
• A clinically signifcant fracture history
defined as the presence of either

16. • As childhood fractures are very common, this definition aims
to distinguish children with an underlying condition from
those who experience fractures as a result of typical
childhood behavior or non-accidental trauma.

17. • A 16-year-old boy presented to the emergency
department with severe back pain.
• A CT scan of the lumbar spine showed an L-2
compression fracture with approximately 19° of loss
of height anteriorly.

18. 1 or more
vertebral compression fractures occurring without high
energy trauma or local disease.

19. A clinically significant fracture

20. fracture
• History of fracture with minimal trauma (eg, ground-level fall) is strongly
suggestive of osteoporosis.
Fragility

21. So, a clinically significant fracture is defined by
The
number
The inciting
cause

22. • A 15-year-old boy presented to the emergency
department with severe back pain.
• A CT scan of the lumbar spine showed an L-2
compression fracture with approximately 19° of loss
of height anteriorly.
• By probing, he doesn’t remember any significant
trauma.

24. •1 or more vertebral compression fractures
occurring without high
energy trauma or local disease
irrespective of Z score.

25. According to the International Society for Clinical
Densitometry (ISCD), pediatric osteoporosis is defined by
one or more vertebral compression fractures
without high energy trauma or local disease
irrespective of the BMD
The combination of a BMD Z-score≤−2 & a clinically
significant fracture history defined as
2 or more long bone fractures before
the age of 10
3 or more long bone fractures at
any age up to 19
OR

26. There are
several
challenges in
using this
definition.
• The risk of underdiagnosing
conditions predisposing to
osteoporosis, e.g. whilst
waiting for the second or
third fracture in children with
low BMD or because the
BMD Z-score is above-2
despite recurrent fractures

27. Metabolic
bone disease
--mineralization
Children 
Rickets
Adult 
OsteoMalacia
Osteoporosis
-- protein matrix
(osteoid)

28. Osteoporosis Osteomalacia
Definition
Reduced bone mass, normal
mineralization
Bone mass variable, reduced
mineralization
Age
Postmenopausal (Type I) or elderly
(Type II)
Any age
Etiology
Endocrine abnormality, age,
idiopathic, inactivity, alcohol, calcium
deficiency
Vit D deficiency or abnormal vit
D pathway, hypophosphatemia,
hypophosphatasia, renal tubular
acidosis
Symptoms and
signs
Pain and tenderness at fracture site
Generalized bone pain and
tenderness
Xray Axial fracture predominance
Appendicular
fracture predominance,
symmetric, includes
pseudofractures (Looser zones)
Serum Ca Normal Low or normal
Serum PO4 Normal Low or normal
ALP Normal
Elevated (except
hypophosphatasia)
Urinary Ca High or normal
Normal or low (high in
hypophosphatasia)
Bone biopsy Tetracycline labeling normal Tetracycline labeling abnormal

29. •Osteo-por-osis

30. What is
osteoporosis?
A systemic skeletal disease
low bone mass
microarchitectural
deterioration of bone
tissue
++bone
fragility
++ fracturerisk

31. Pathophysiology

32. "
‫بقدر‬ ‫خلقناه‬ ‫شيء‬ ‫كل‬ ‫إنا‬
"

33. Imbalance between bone resorption & formation
causes loss of bone substance.

34. Imbalance between bone resorption & formation
causes loss of bone substance.

35. Causes and Risk Factors

36. Risk Factors
Non-modifiable
Age, sex
Personal & family
history of fracture
White race
Modifiable

37. Modifiable risk factors
Cigarette Caffeine AlCohol
Ca– diet
Chronic
diseases
‫ك‬
‫سل‬
Drugs: Corticosteroids,
Convulsion,
Chemotherapy
Endocrinopathies

38. Pediatric
Osteoporosis
Primary Secondary

40. Secondary
osteoporosis

41. Special
population
20. Regarding children of short
stature (< p3) or with a growth
retardation problem, it is
recommended to adjust their results
by means of a size Z-score. (2a B)
21. For children suffering from joint
contracture or with mobility
problems - e.g., with cerebral palsy -
distal femur measurement can be an
alternative.

42. • The7-year CKD patient came 2
months later with low back pain.
• You requested AP & lateral x-ray
lumbosacral & found that she
develop wedge vertebral fracture.

43. 22. For children with suspected
secondary osteoporosis, it is
recommended to extend the study
with a plain lateral thoracic &
lumbar X-ray to assess vertebral
compression fractures, particularly
if they are receiving GCs. (2b B)
23. In the event of low bone mass
or risk factor persistence, a second
plain lateral thoracic and lumbar
X-ray should be taken after one
year.

44. • Vertebral fractures (VFs) may result in scoliosis or kyphosis and, because they
may be clinically silent, it is imperative that vertebral fractures are diagnosed in
children accurately and at an early stage, so the necessary medical care can be
implemented.

45. Traditionally, diagnosis of osteoporotic VFs has been from lateral spine
radiographs.
A small number of studies showed that DXA is comparable to radiographs for
identifying VFs in children, while allowing less radiation exposure. The
diagnosis of VFs from DXA is termed vertebral fracture assessment (VFA).
Existing scoring systems for VFA in adults have been assessed for use in
children, but there is no standardisation & observer reliability is variable.

46. Selected lateral spine
dual energy x-ray
absorptiometry scans
from a series of patients
demonstrate the
semiquantitative visual
grading system of Genant
et al.
The Genant semi-quantitative method is a
morphometric assessment of vertebrae
used in adults and children
≥ 20% loss in vertebral height ratio
accepted as clinically significant.

47. Corticosteroid-induced osteoporosis
46 Lateral spine x-ray is recommended in order to detect
VF at the beginning of treatment with GCs & after one
year. (2a B)
47 It is recommended to carry out lumbar spine or TBLH
DXA within the first 6 months after the beginning of
treatment with GCs, & then every 9 to 12 months if
treatment continues. (4 D 85%)
48 It is recommended to start simultaneous treatment &/
or optimize calcium intake (500–1000 mg/day) & vitamin
D 400 IU/day for those patients who are scheduled to
receive systemic GCs for three months or more. (2b B)

48. Corticosteroid-
induced osteoporosis
• 49 Treatment with calcium & vitamin D must
be maintained for 3 months after
discontinuation of GCs. (5 D 88%)
• 50 For children & adolescents receiving GCs
chronically & presenting low BMD (Z-score ≤ −
2) & pathological fractures, it is recommended
to use BPs associated with calcium & vitamin
D. (1b A)
• 51 Lateral spine x-rays or BMD checks with
DXA are not recommended on a routine basis
for those children & adolescents being treated
with inhaled GCs at dosages under 800
mcg/day, unless they present other risk
factors. (1b A)

49. Management of children with secondary
osteoporosis due to chronic
disease/longstanding GC therapy.

50. Restoring the balance between bone resorption &
formation causes loss of bone substance

51. Restoring the balance between bone resorption &
formation causes loss of bone substance
Antiresorptive treatment Bone forming
(Anabolic)

52. •Anabolic treatments
for bone such as
recombinant
parathormone
(teriparatide) are
contraindicated in
children.

53. 4. Curative treatment with bisphosphonates (French
working group guidelines 2020)
IV bisphosphonates (pamidronate or zoledronate)
in case of symptomatic bone fragility according to
the definition (vertebral fracture and/or clinically
significant long bone fractures & BMD Z-score <
−2) (A) or in case of chronic bone pain & BMD Z-
score < −2 (expert opinion)

54. 4. Curative treatment with bisphosphonates (French working
group guidelines 2020)
Bisphosphonates are not indicated in case of isolated low BMD (without
fractures) (A), to be discussed on a case-by-case basis in specialized
centers (expert opinion)
Depending on the "course" of the disease due to the potential for
spontaneous healing, to be discussed on a case-by-case basis in specialized
centers (expert opinion)
Oral bisphosphonates are not indicated on the basis of current data (B)

55. SERPE recommendations
33. Treatment with BP can be considered for patients without
osteoporosis, but a low BMD in early puberty (Tanner 2):
When active risk factors are present:
patients with Z ≤ − 2. 5 SD (with a
declining trajectory confirmed at least
on 2 separate occasions 1 year apart).
When patients no longer present active
risk factors: patients with Z ≤ -3DS (with
a declining trajectory confirmed on at
least on 2 separate occasions 1 year
apart). (5 D 78%)
32. Treatment with BP should be administered to those pediatric
patients with osteoporosis (Z-score ≤ − 2 & pathological fracture or VF
regardless of Z-score). (1b A)

56. SERPE recommendations
34. IV BPs should
be used whenever
there are VF, if
there is some
contraindication
to the use of oral
BPs, or according
to the patient’s
preferences. (3a
B-C)
35 Oral BPs can be
used in the
absence of
contraindications
& VF, or during
the de-escalation
phase. (5 D 70%)
36 The BP dosage
should be
discontinued or
progressively
reduced in patients
not presenting
fractures during
the preceding year
& having reached a
Z-score > -2. (5 D 9)

57. Precautions for the use of bisphosphonates

60. Take aways
Diagnosing osteoporosis should
not be based on BMD alone but
take into account the clinical
context, specifically the severity
& prognosis of the underlying
disease or treatment.
It is generally said that if the
skeletal structure of a child is
weak, it is very likely to remain
weak into adult life.

61. THANK YOU
‫خيرا‬ ‫هللا‬ ‫جزاكم‬

62. • The challenges of interpretation of DXA BMD and the
• need for size correction are now well recognized. There
• are numerous methods to adjust DXA-measured BMD
• (e.g., height, bone age, puberty, lean mass, weight). While
• the recent ISCD position recommends height adjustment
• for total body BMD and volumetric adjustment with BMAD at the lumbar spine, studies show that different
• methods of size adjustment of DXA-measured BMD at
• the lumbar spine were closely correlated in group analysis, although this is likely to differ for an individual patient.
Using a different method of size adjustment for
• DXA bone parameters did not change their relationship
• with vertebral fracture (VF), although the utility of different methods of size adjustment for individual fracture
• prediction is unclear [31, 32] .