CHILDREN'S OSTEOPOROSIS = presence of fragility fractures.
The International Society of Clinical Densitometry (ISCD), in its latest consensus of 2019,
considers two possible conditions for the diagnosis of childhood osteoporosis:
– Presence of one or more vertebral fractures in the absence of local disease or
high energy trauma.
– BMD or BMC Z-score less than -2 (adjusted to height in children size < P3) associated with
a history of clinically significant fractures, considered as such:
– Two or more long bone fractures under the age of 10.
– Three or more long bone fractures under the age of 19

** A Z-score greater than -2 does not exclude the possibility of bone fragility and predisposition to
suffer fractures, especially in those patients affected by pathologies that favor the appearance of
2nd osteoporosis: **Immobility, pubertal delay, little sun exposure, nutritional deficiency, sustained inflammatory activity and exposure to osteotoxic drugs, such as corticosteroids or antiepileptics.

In infants and preschoolers:
Lumbar DXA = 3 years

https://zscore.research.chop.edu/calcpedbonedens.php

https://www.bedca.net/bdpub/index.php

The recommended daily dose of vitamin D in the healthy child:
– 1 year: 600 IU
The American Academy of Pediatrics recommends vitamin D supplementation in:

  • All newborns (first days of life until one year of age).
  • Children 1-2 years old who must drink milk or skimmed milk products.
  • Children who drink < 1 L of milk not fortified with vitamin D.
  • Adolescents who do not take 400 IU/day.
  • Children at risk of vitamin D deficiency (malabsorption, antiepileptic medication...) should
    receive higher doses daily based on the serum level of 25 OH vitamin D. Monitor
    every 6 months.
  • There is NO recommended daily dose of calcium and vitamin D in children with chronic pathologies.
  • In children affected by chronic pathologies with low BMD for chronological age: supplement with calcium and
    vitamin D at the recommended doses in healthy children and modify its dose depending on iPTH, calciuria and
    vitamin D levels.
  • Diet rich in fruits and vegetables
  • Oral or inh corticosteroid therapy. Calcium and vitamin D should be supplemented if prednisone dose > = 5 mg/day

In the latest consensus on the use of bisphosphonates in children and adolescents, it is
They always recommend that they meet osteoporosis criteria.
GOAL: Prevent new fragility fractures
They can be considered in patients WITHOUT osteoporosis, but with low BMD at the beginning of treatment.
puberty (Tanner 2) in two situations:

  • If the risk factors persist and the Z-score is < -2.5 with a downward trend
    in two determinations separated by at least one year.
  • In the absence of risk factors, if the Z-score is < -3 with a downward trend in
    two determinations separated by at least one year.

General well tolerated.
■ IV bisphosphonates:
– Flu-like syndrome with fever, malaise, nausea, diarrhea and generalized myalgia at the beginning of treatment. 1st and 3rd day of
treatment, last a few days and rarely recur in successive doses. They subside with paracetamol.
– Asymptomatic hypocalcemia, in some cases arrhythmias, laryngospasm and tetany.
– Asymptomatic hypophosphoremia and hypomagnesemia
– Others: uveitis, thrombopenia or oral or esophageal ulcers and osteonecrosis of the jaw
** TO REDUCE RISK:
Request ionic calcium 48 hours after the infusion
Ensure adequate levels of vitamin D and calcium before starting treatment.
Dental checkup before and every 6 months during bisphosphonate therapy.
Discontinue treatment 3 to 4 months before any elective osteotomy and restart only when the callus is
formed.
Kidney ultrasound: detect nephrocalcinosis in relation to vitamin D supplementation
Calcemia monitoring of newborns of mothers treated with bisphosphonates before or during pregnancy.

INSTRUCTIONS FOR THE ADMINISTRATION OF
PAMIDRONATE/ZOLEDRONATE
Before each infusion check vitamin D >= 30 ng/dL, normal calcium and kidney function.
For the first infusion, administer half the dose.
Administer paracetamol before the infusion to reduce side effects (fever,
pain).
Administer (or increase) calcium supplements the week before and the week before
after treatment.

■ DXA, depending on the treatment they receive.
– If prolonged corticosteroid treatment: Annually or Biennially while the treatment lasts and even every 6
months, with the first recommended 3 months after the start of corticosteroid therapy.
– In patients with chronic diseases who do not receive treatment with corticosteroids, there is no consensus,
must be individualized according to:

  • the underlying disease,
  • bone quality at initial evaluation,
  • the nutritional status,
  • lifestyle habits and
  • the appearance of fractures
    ■ Spinal X-ray: after one year if low bone mass or risk factor persists.
    ■ Analytics: annual
    ■ Renal ECHO: if hypercalciuria to rule out nephrocalcinosis.

the underlying disease, the quality of the bone in the initial evaluation, the nutritional status, lifestyle habits and the appearance of fractures. ■ Spinal X-ray: after one year if low bone mass or risk factor persists. ■ Analytics: annual. ■ Renal ECHO: if hypercalciuria, to rule out nephrocalcinosis.