The Journal of the Arkansas Medical Society Med Journal June 2020 | Page 13

AFMC: A CLOSER LOOK AT QUALITY
from 60-100 ng/mL. Vitamin D level
should be assessed every six months
in children receiving targeted supplementation
or those with LBD. Recommended
daily allowance is 400 IU
per day for infants <12 months and
600 IU per day for older children. The
vitamin D dose may need to be several
thousand units daily to achieve
target serum levels in children with
clinically significant LBD. 4,2
Additional modifiable risk factors
related to bone density include soda
consumption and weight-bearing
exercise. 1 Soda consumption can
interfere with absorption of vitamin
D and calcium. If children are taking
these supplements, they should not
drink soda. Weight-bearing exercise
is more challenging in children
with mobility impairments (such as
cerebral palsy). Only minimal gains
are reported with use of a static
standing frame in this population.
It should not be utilized as the sole
method to improve or maintain
bone density in those with impaired
mobility. 4 Exercise is important to
improve bone density, but it comes
with increased risk for those with
LBD. Even getting dressed can result
in fracture. Range of motion exercises
should be done cautiously with
LBD children. The child’s therapists
and other professionals should be
informed of LBD, as this can impact
care plans. A physical medicine and
rehabilitation specialist (PM&R) can
provide detailed recommendations
to therapists.
Osteogenesis imperfecta is known
to cause fracture-prone bones. Other
pediatric conditions can result in
osteoporosis, 2,1 including connective
tissue disorders, such as Marfan’s
syndrome and Ehlers-Danlos.
Inflammatory conditions, such as
juvenile rheumatoid arthritis, lupus
and inflammatory bowel disease
can decrease bone production
and increase resorption. Impaired
absorption of calcium and vitamin
D can occur in children with chronic
kidney or liver disease, milk allergy,
cystic fibrosis, short gut or celiac
disease. Hormonal imbalances
can adversely impact bone health,
including abnormal corticosteroid
production, hypogonadism,
hypothyroidism, Turner syndrome,
idiopathic short stature and exerciseinduced
amenorrhea. Those with
prolonged immobility, asthma,
hemophilia and anemia are at
risk for LBD due to lack of activity.
Children with impaired mobility
related to cerebral palsy, spina
bifida, spinal cord injury, brain injury
or muscular dystrophy are at high
risk of LBD. 5,4 Pediatric cancer is
strongly associated with LBD, due
to prolonged immobility and sideeffects
of essential medications. A
fracture in any of these populations
can be devastating, impacting
mobility and function in an already
impaired child.
Medications are a frequent
iatrogenic cause of pediatric
osteoporosis. Often, these are
unavoidable as the conditions they
treat (cancer, seizures, etc.) are more
detrimental than osteoporosis.
Corticosteroid use is often
required to treat inflammatory or
autoimmune conditions, and care
must be taken to address additional
modifiable risk factors. Some
medications may be substituted,
particularly in individuals at high
risk of fractures. For example, the
use of depot medroxyprogesterone
for menstrual suppression or birth
control is ill-advised in a child
who has spina bifida. 6,7 Other
medications that may lower bone
density include seizure medications,
proton-pump inhibitors, loop
diuretics and oral anticoagulants.
In those with LBD, medication
management and exercise recommendations
are essential. 4 PM&R
specialists can help with activity
and exercise recommendations. If
vitamin D supplementation is insufficient,
refer to an endocrinologist.
Bisphosphonates, which can be helpful
in the adult population, are not as
well studied in pediatrics. The choice
to use these medications is best left
to a specialist in bone health. s
Dr. Hobart-Porter is an assistant
professor at UAMS; medical director,
Spinal Cord Disorders Program and
Concussion Clinic, Arkansas Children’s
Hospital; and medical director, Easter
Seals Rehabilitation Center.
REFERENCES
1. Steffey C. (2019). Pediatric Osteoporosis.
Pediatrics in Review, 40(5),259-261.
2. Yasar E, Adiguzel E, Arslan M, et.al. (2018).
Basics of bone metabolism and osteoporosis
in common pediatric neuromuscular
disabilities. European J of Paediatric Neurology,
22(1), 17-26.
3. Binkovitz L, Sparke P, Henwood M. (2007).
Pediatric DXA: Clinical Applications. Pediatric
Radiology, 37, 625-635.
4. Alexander M, Matthews D. (2015). Pediatric
Rehabilitation: Principles and Practice. New
York, NY: Demos Medical.
5. Dosa N, Eckrich M, Katz D. (2007). Incidence,
prevalence and characteristics of fracture in
children, adolescents, and adults with spina
bifida. J Spinal Cord Med, 30 (S1), S5-S9.
6. Spina Bifida Association. (2018, Nov. 30).
www.spinabifidaassociation.org/guidelines.
Retrieved 9-30-19
7. Jackson A, Mott P. (2007). Reproductive
health care for women with spina bifida. The
Scientific World Journal, 7, 1875-1883.
AFMC WORKS COLLABORATIVELY WITH PROVIDERS,
COMMUNITY GROUPS AND OTHER STAKEHOLDERS TO
PROMOTE THE QUALITY OF CARE IN ARKANSAS THROUGH
EDUCATION AND EVALUATION. FOR MORE INFORMATION
ABOUT AFMC QUALITY IMPROVEMENT PROJECTS,
CALL 1-877-375-5700 OR VISIT AFMC.ORG.
JUNE 2020
Volume 116 • Number 12 JUNE 2020 • 277