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Introduction: Pediatric metabolic bone and mineral disorders encompass a wide variety of disorders that can be challenging to diagnose and treat because of inadequate physician training about optimal management. Methods: As practice variation and confidence levels may impact clinical outcome, we sought to assess physician confidence in managing pediatric metabolic bone and mineral disorders and the spectrum of treatment practices among members of the Pediatric Endocrine Society (PES) and the Canadian Pediatric Endocrine Group (CPEG). Questionnaires were distributed via e-mail to all members of the PES and CPEG and 244 were completed. Responses were summarized using descriptive statistics, and proportions were compared using χ2 or Fisher’s exact tests, as appropriate. Results: Variations were observed among the respondents’ confidence in the management of bone disorders and in the criteria used to initiate/discontinue intravenous bisphosphonates or prescribe burosumab therapy. Respondents felt confident with the management of 4 out of 20 pediatric bone conditions (confidence was defined as >90% of respondents reporting feeling “somewhat confident” or “very confident”). Physicians working in a bone clinic were more confident in prescribing burosumab for the treatment of X-linked hypophosphatemic rickets compared to those not working in a bone clinic (65% vs. 47%, p = 0.03). Most respondents (52%) reported having received inadequate training in pediatric metabolic bone and mineral disorders. Discussion/Conclusion: Dedicated training, knowledge acquisition, and education resources are needed to increase confidence and standardize the use of bone-targeted therapies.

* Abbreviations: aBMD — : areal bone mineral density BMAD — : bone mineral apparent density DXA — : dual energy radiograph absorptiometry GnRHa — : gonadotropin hormone releasing hormone agonists Recognition and support are growing for the estimated 0.7% of American teenagers who identify as transgender or gender fluid.1 Many children’s hospitals now offer multidisciplinary care to patients to assist them in transitioning from their designated sex at birth (natal sex or sex assigned at birth) to their affirmed gender. Therapy can begin in early puberty with suppression of sex steroid hormone production followed by supplementation with sex steroids appropriate for their gender identity. The duration of pubertal suppression with gonadotropin hormone releasing hormone agonists (GnRHa) varies but can be as long as 4 years for younger patients who must wait until age 16 to consent for receipt of gender-affirming sex steroid replacement. Much remains unknown about how these manipulations in sex steroids will impact bone geometry, turnover, mass, and strength, all of which contribute to peak bone mass and strength in early adulthood. Peak bone mass and strength attained by early adulthood reflects the culmination of genetic and modifiable influences on bone density and microstructure.2 Sex steroids have differing effects on bone geometry during puberty, with testosterone fostering apposition of bone on the outer cortical surface and estrogen modifying the internal, endocortical area of bone.3 Research into the skeletal effects of hormone therapy for transgender youth is a high priority. The treatment protocols provide a valuable opportunity to distinguish the relative influence of sex steroids versus genetic preprogramming in determining bone development. Beyond the academic questions to be addressed, the onus is on providers to determine if their patients will sustain any adverse effects with respect to their long-term bone health. The influence of this treatment on the skeleton can be assessed noninvasively with dual energy radiograph absorptiometry (DXA), standard or high-resolution peripheral computed tomography, and/or MRI. These tools … Address correspondence to Laura K. Bachrach MD, Department of Pediatrics, Stanford University, 453 Quarry Road, Stanford, CA 94305-5660. E-mail: lkbach{at}stanford.edu

Osteoporosis is an under-recognized complication of chronic illness in childhood. This review will summarize recent literature addressing the risk factors, evaluation, and treatment for early bone fragility. Criteria for the diagnosis of pediatric osteoporosis include the presence of low trauma vertebral fractures alone or the combination of low bone mineral density and several long bone fractures. Monitoring for bone health may include screening for vertebral fractures that are common but often asymptomatic. Pharmacologic agents should be offered to those with fragility fractures especially when spontaneous recovery is unlikely. Controversies persist about the optimal bisphosphonate agent, dose, and duration. Newer osteoporosis drugs have not yet been adequately tested in pediatrics, though clinical trials are underway. The prevalence of osteoporosis is increased in children with chronic illness. To reduce the frequency of fragility fractures requires increased attention to risk factors, early intervention, and additional research to optimize therapy and potentially prevent their occurrence.

Context: Deficient anterior pituitary with variable immune deficiency (DAVID) syndrome is a rare disorder in which children present with symptomatic adrenocorticotropic hormone (ACTH) deficiency preceded by hypogammaglobulinemia from B-cell dysfunction with recurrent infections, called common variable immunodeficiency (CVID). Subsequent whole exome sequencing studies have revealed germline heterozygous C-terminal mutations of NFKB2 as a cause of DAVID syndrome or of CVID without clinical hypopituitarism. However, to the best of our knowledge there have been no cases in which the endocrinopathy has presented in the absence of a prior clinical history of CVID. Case Description: A previously healthy 7-year-old boy with no history of clinical immunodeficiency presented with profound hypoglycemia and seizures. He was found to have secondary adrenal insufficiency and was started on glucocorticoid replacement. An evaluation for autoimmune disease, including for antipituitary antibodies, was negative. Evaluation unexpectedly revealed hypogammaglobulinemia [decreased immunoglobulin G (IgG), IgM, and IgA]. He had moderately reduced serotype-specific IgG responses after pneumococcal polysaccharide vaccine. Subsequently, he was found to have growth hormone deficiency. Six years after initial presentation, whole exome sequencing revealed a de novo heterozygous NFKB2 missense mutation c.2596A>C (p.Ser866Arg) in the C-terminal region predicted to abrogate the processing of the p100 NFKB2 protein to its active p52 form. Conclusions: Isolated early-onset ACTH deficiency is rare, and C-terminal region NFKB2 mutations should be considered as an etiology even in the absence of a clinical history of CVID. Early immunologic evaluation is indicated in the diagnosis and management of isolated ACTH deficiency.

Tumor-induced osteomalacia (TIO) is a rare cause of hypophosphatemia involving overproduction of fibroblast growth factor 23. TIO has been described largely in adults with small mesenchymal tumors. We report a case of TIO in a child who presented with knee pain and radiographic findings concerning for rickets, and was found to have maxillomandibular giant cell lesions. The patient was treated with oral phosphorus and calcitriol, surgical debulking, and intralesional corticosteroids, which resulted in tumor regression and normalization of serum fibroblast growth factor 23 and phosphorus. This case illustrates the occurrence of this rare paraneoplastic syndrome in children and adds to our knowledge about clinical manifestations and pathologic findings associated with pediatric TIO.

Purpose Adolescents with anorexia nervosa (AN) face an increased lifetime risk of bone fragility. This randomized controlled study examined the efficacy and safety of a high-impact activity program on markers of bone turnover and stabilization of vital signs (VSS). Methods Forty-one hospitalized adolescents with AN were randomly assigned to routine care or routine care plus 20 jumps twice daily. Bone markers were measured at baseline days 1–3 (T1), days 4–6 (T2), and days 7–9 (T3). The primary outcome was change in bone-specific alkaline phosphatase (BSAP) at T3 adjusted for BSAP and % median body mass index at T1. Secondary outcomes were serum N-telopeptide (NTX) and osteocalcin at T3. Safety was determined by comparing weight gain, time to VSS and length of stay for each group. Results BSAP, NTX, or osteocalcin did not differ between groups at baseline or at T3. BSAP and NTX at T3 were not associated with group of enrollment or % median body mass index. VSS was significantly reduced in the intervention group compared with the control group (11.6 ± 5.7 days vs. 17 ± 10.5 days, p = .049). There was no significant difference in weight gain or length of stay between groups. Conclusions Twice-daily jumping activity failed to influence markers of bone turnover in adolescents with AN but was well tolerated, shortened time to vital-sign stabilization and did not slow weight gain.

* Abbreviation: BMD — : bone mineral density By 16 years of age, up to 40% of otherwise healthy girls and 64% of boys will have experienced ≥1 broken bone, with a peak incidence in the peri-pubertal years.1 Is this just because youth are active or risk takers? An alternative explanation is that the fastest rate of bone mineralization occurs several months after the most rapid gains in bone size during adolescence.2 The incidence of childhood fractures appears to be on the rise in both the United States and Scandinavia, raising concerns about unhealthy lifestyle trends.1 Addressing this public health problem requires an understanding of which children are fracturing bones and why. In the population-based retrospective study of emergency department visits from Ontario, Canada, in this issue of Pediatrics , Escott et al3 suggest the risk of a broken bone is not equal for all. The study compared the fracture incidence for those with or without a baseline fracture over a 7-year follow-up period. To focus on healthy youth (

The departure of physician-scientists from education and research into clinical practice is a growing challenge for the future of academic medicine. Junior faculty face competing demands for clinical productivity, teaching, research, and work-life integration, which can undermine confidence in the value of an academic career. Mentorship is important to foster career development and satisfaction in junior faculty.The goals of this academic pediatrics department were to develop, implement, and evaluate a multifaceted pediatric mentoring program to promote retention and satisfaction of junior faculty. Program elements included one-on-one mentor-mentee meetings, didactic workshops, grant review assistance, and facilitated peer-group mentoring. Program effectiveness was assessed using annual surveys of mentees and structured mentee exit interviews, as well as retention data for assistant professors.The mentees were instructors and assistant professors in the department of pediatrics.Seventy-nine mentees participated in the program from 2007 through 2014. The response rate from seven annual surveys was 84%. Sixty-nine percent of mentees felt more prepared to advance their careers, 81% had a better understanding of the criteria for advancement, 84% were satisfied with the program, and 95% found mentors accessible. Mentees who exited the program reported they most valued the one-on-one mentoring and viewed the experience positively regardless of promotion. Retention of assistant professors improved after initiation of the program; four of 13 hired from 2002 to 2006 left the institution, whereas 18 of 18 hired from 2007 to 2014 were retained.This multifaceted mentoring program appeared to bolster satisfaction and enhance retention of junior pediatric faculty. Mentees reported increased understanding of the criteria for promotion and viewed the program as a positive experience regardless of career path. Individual mentor-mentee meetings were needed at least twice yearly to establish the mentoring relationship. Identifying "next steps" at the end of individual meetings was helpful to hold both parties accountable for progress. Mentees most valued workshops fostering development of tangible skills (such as scientific writing) and those clarifying the criteria for promotion more transparent. Facilitated peer-group mentoring for mentees at the instructor rank provided valuable peer support.

Background A supportive working environment can be protective against burnout in residency training. To help foster a positive culture, we developed the 'Golden Ticket Project' (GTP) and evaluated it as a tool for peer appreciation. Methods In October 2013-July 2014, all paediatric residents (n = 83) at a paediatric residency programme were invited to participate in the GTP. Through an electronic form, residents could award a co-resident with a 'Golden Ticket' for any behaviour that they were grateful for. Two authors manually coded and analysed the tickets using content analysis to identify recurring themes. We also distributed an anonymous survey to all residents to assess their attitudes toward the GTP. Results The majority (61%) of residents either gave or received 'Golden Tickets' (51/83). Reasons for receiving tickets fell into five categories: (i) teamwork; (ii) positive attitude; (iii) patient care; (iv) resident-resident support; and (v) supervisory skills. Across all three classes, teamwork was recognised most frequently, noted in 43% of all tickets. The recognition of other behaviours varied by class. Fifty-five percent (46/83) of residents completed the programme evaluation survey. Seventy-six percent (35/46) of respondents wanted the programme to continue; of those, 49% (17/35) 'agreed' or 'strongly agreed' that they were 'more aware of acts of kindness in the residency program because of the GTP'. A supportive working environment can be protective against burnout in residency training DISCUSSION: The GTP is a feasible and valued peer-support initiative for residents. The GTP characterised behaviours and attitudes that residents were grateful for in their peers. These behaviours could inform the development of wellness interventions for residents that focus on building supportive working environments.

The diagnosis and management of osteoporosis in adolescents differ in several ways from the care of older adults. The diagnosis cannot be based upon low bone mineral density alone. The criteria for osteoporosis in a pediatric patient include a low trauma vertebral fracture or low bone density for age and a significant fracture history (2 or more long bone fractures before age 10 or 3 or more long bone fractures before age 19). Since many vertebral fractures are asymptomatic, radiographic screening is important for youth at high risk. Primary osteoporosis results from heritable disorders, whereas secondary osteoporosis is acquired as a consequence of chronic disease and the medications used for treatment. The myriad disorders linked to bone fragility share one or more common skeletal risk factors including nutritional deficits, reduced mobility, increased inflammatory cytokines, sex steroid or growth hormone deficiency, and osteotoxic drug therapy. The net result is reduced bone formation, which may be compounded by increased bone resorption. Growing children have the potential to restore bone strength if they recover from illness, whereas pharmacologic therapy may be indicated on a compassionate basis for patients with fragility fractures and limited potential to recover spontaneously. Primary care providers can play a critical role by identifying teens at risk for bone fragility, by encouraging optimal nutrition (including protein, calcium, and vitamin D) and physical activity, and by referring to physicians with expertise in pediatric osteoporosis. The goal of this chapter is to educate providers about current consensus and controversy on the use of osteoporosis drugs in adolescents.

Burnout is a work-related syndrome characterized by emotional exhaustion (EE), depersonalization (DP), and lack of personal accomplishment (PA). We hypothesized that the transition into an environment of high physical, intellectual, and emotional demands of the medical profession would lead to an increase in the prevalence of burnout in pediatric residents, which would remain high throughout residency.The Maslach Burnout Inventory (MBI) was administered to pediatric residents at Lucile Packard Children's Hospital 6 times between February 2010 and February 2012. These times corresponded to the start of residency, mid-intern year, end-intern year, mid-junior year, end-junior year, and mid-senior year.Mean values of burnout components changed significantly between the start of residency and mid-intern year. EE increased from 15.8 to 24.5 (P.001), DP increased from 4.5 to 9.2 (P.001), and PA decreased from 40.2 to 38.3 (P = .04). Similarly, the prevalence of burnout increased from 17% to 46% (P = .012), or 2% to 24% (P = .002) using more restrictive criteria, between the start of residency and mid-intern year. Significant changes in mean scores or prevalence of burnout were not found between any other consecutive times throughout residency.This longitudinal study documented a significant increase in the components of burnout among pediatric residents between the start of residency and mid-intern year, which persisted through the PGY2 and PGY3 years. Further studies are warranted to identify correlates of resident burnout and to develop preventative strategies to reduce its occurrence.

Concerns about bone health and potential fragility in children and adolescents have led to a high interest in bone densitometry. Pediatric patients with genetic and acquired chronic diseases, immobility, and inadequate nutrition may fail to achieve expected gains in bone size, mass, and strength, leaving them vulnerable to fracture. In older adults, bone densitometry has been shown to predict fracture risk and reflect response to therapy. The role of densitometry in the management of children at risk of bone fragility is less clear. This clinical report summarizes current knowledge about bone densitometry in the pediatric population, including indications for its use, interpretation of results, and risks and costs. The report emphasizes updated consensus statements generated at the 2013 Pediatric Position Development Conference of the International Society of Clinical Densitometry by an international panel of bone experts. Some of these recommendations are evidence-based, whereas others reflect expert opinion, because data are sparse on many topics. The statements from this and other expert panels provide general guidance to the pediatrician, but decisions about ordering and interpreting bone densitometry still require clinical judgment. The interpretation of bone densitometry results in children differs from that in older adults. The terms “osteopenia” and “osteoporosis” based on bone densitometry findings alone should not be used in younger patients; instead, bone mineral content or density that falls >2 SDs below expected is labeled “low for age.” Pediatric osteoporosis is defined by the Pediatric Position Development Conference by using 1 of the following criteria: ≥1 vertebral fractures occurring in the absence of local disease or high-energy trauma (without or with densitometry measurements) or low bone density for age and a significant fracture history (defined as ≥2 long bone fractures before 10 years of age or ≥3 long bone fractures before 19 years of age). Ongoing research will help define the indications and best methods for assessing bone strength in children and the clinical factors that contribute to fracture risk. The Pediatric Endocrine Society affirms the educational value of this publication.

Skeletal health in childhood and adolescence influences the lifetime risk of bone fragility. Peak bone mass (PBM) reached by early adulthood serves at the “bone bank” for life. For this reason, optimizing bone acquisition in the first two decades can help prevent osteoporosis. Genetic factors determine an estimated 60–80 % of variability in PBM; hormones and nutrition, activity, and other modifiable factors account for the remainder. The expected gains in bone mass and size during the critical growing years can be compromised by several heritable or acquired disorders. Recognizing and addressing threats to bone health are essential to reducing the risk of bone fragility. Bone densitometry is a valuable noninvasive means to identify those at greatest risk for fracture. Although several new methods for assessing bone mass and geometry have evolved in recent years, dual energy x-ray absorptiometry (DXA) remains the recommended densitometry device for clinical use in pediatrics. The availability of robust pediatric normative data and creation of expert guidelines for pediatric densitometry have made DXA an even more valuable diagnostic tool. This book will highlight the clinical utility of DXA for pediatrics including the rationale for when and how to employ it. The overarching goal of this book is to serve as a resource for those acquiring, interpreting, reporting, and utilizing densitometry in pediatric patients. The purpose of this chapter is to review the acquisition of PBM in health and disease and briefly summarize the potential and limitation of bone densitometry in monitoring skeletal development in the growing patient.

Summary Background Reduced bone mass and fractures are known complications of generalized forms of epidermolysis bullosa (EB). However, the aetiology – inadequate bone acquisition, premature bone loss, or a combination – is unclear. Objectives To determine patterns of bone mineral acquisition in children with EB and to identify clinical and laboratory correlates of change in areal bone mineral density (aBMD). Methods Seventeen subjects ≥ 6 years of age with generalized EB were studied at two visits at least 12 months apart with clinical and laboratory evaluations and dual energy X-ray absorptiometry scans of the lumbar spine. Wilcoxon signed-rank tests were used to determine if changes from baseline to follow-up were significant. Wilcoxon rank-sum tests were used to compare subjects with gains in aBMD Z-score with those who experienced no change or decreases to determine if baseline laboratory or clinical characteristics differed between the two groups. Results Subjects gained height and weight at follow-up, but there was no significant improvement in mean Z-scores for height, weight or body mass index. Laboratory values did not change significantly. Mean bone mineral content and aBMD of the lumbar spine increased significantly at follow-up, but mean aBMD Z-scores remained static. No differences in clinical characteristics or laboratory values were seen between subjects with increased aBMD Z-scores vs. those whose scores decreased or did not change. Conclusions Low bone mass in children with generalized EB is due primarily to inadequate gains in aBMD. Interventions to improve overall health and to help build bone mass in this patient population are warranted.

Concern for bone fragility in children and adolescents has led to increased interest in bone densitometry. Pediatric patients with genetic and acquired chronic diseases, immobility, and inadequate nutrition may fail to achieve the expected gains in bone size, mass, and strength, which leaves them vulnerable to fracture. In older adults, bone densitometry has been shown to predict fracture risk and reflect response to therapy. The role of densitometry in the management of children at risk of bone fragility is less certain. This clinical report summarizes the current knowledge about bone densitometry in the pediatric population, including indications for its use, interpretation of results, and its risks and costs. This report emphasizes consensus statements generated at the 2007 Pediatric Position Development Conference of the International Society of Clinical Densitometry by an international panel of bone experts. Some of these recommendations are evidence-based, and others reflect expert opinion, because the available data are inadequate. The statements from this and other expert panels have provided general guidance to the pediatrician, but decisions about ordering and interpreting bone densitometry still require clinical judgment. Ongoing studies will help to better define the indications and best methods for assessing bone strength in children and the clinical factors that contribute to fracture risk.

It is unclear why some adolescents experience substantial bone mineral density (BMD) loss, while others experience a minimal decrease during depot medroxyprogesterone acetate (DMPA) use. We examined biopsychosocial factors in adolescents who experienced ≥5% BMD loss from baseline compared with adolescents who experienced5% BMD loss during DMPA use.A multicenter, prospective, nonrandomized study of 181 female adolescents who initiated DMPA for contraception was conducted. BMD (by dual-energy X-ray absorptiometry) and serum estradiol were measured at initiation and every 6 months for 240 weeks of DMPA use.Half of participants experienced BMD loss of ≥5% from baseline at the hip, and a quarter experienced BMD loss of ≥5% at the lumbar spine (BMD substantial losers, SL). Hip and lumbar spine BMD-SL received a significantly greater number of DMPA injections than non-SL (p.001). Decreased estradiol levels did not statistically differ between BMD loss subgroups. Hip BMD-SL had significantly lower baseline body mass index (BMI) than non-SL (p=.002), and there was an inverse relationship between weight gain and degree of BMD loss. Mean calcium intake was significantly lower (p.05) in hip BMD-SL, and reported alcohol use was significantly higher (p.05) in lumbar spine BMD-SL compared with non-SL.BMD loss of ≥5% was more common at the hip than at the lumbar spine among adolescents using DMPA. Decreased serum estradiol levels did not correlate with magnitude of BMD loss. Lower BMI and calcium intake and greater alcohol use were associated with greater BMD loss in adolescents using DMPA.

Fractures are common in childhood and adolescence, with an estimated 30% of this population experiencing at least 1 broken bone. The forearm is the most common fracture site.In the absence of major trauma, fractures of the femur and spine are suggestive of abnormal bone fragility; such cases warrant

To identify nutrients, foods, and dietary patterns associated with stress fracture risk and changes in bone density among young female distance runners.Two-year, prospective cohort study. Observational data were collected in the course of a multicenter randomized trial of the effect of oral contraceptives on bone health.One hundred and twenty-five female competitive distance runners ages 18-26 years.Dietary variables were assessed with a food frequency questionnaire.Bone mineral density and content (BMD/BMC) of the spine, hip, and total body were measured annually by dual x-ray absorptiometry (DEXA). Stress fractures were recorded on monthly calendars, and had to be confirmed by radiograph, bone scan, or magnetic resonance imaging.Seventeen participants had at least one stress fracture during follow-up. Higher intakes of calcium, skim milk, and dairy products were associated with lower rates of stress fracture. Each additional cup of skim milk consumed per day was associated with a 62% reduction in stress fracture incidence (P.05); and a dietary pattern of high dairy and low fat intake was associated with a 68% reduction (P.05). Higher intakes of skim milk, dairy foods, calcium, animal protein, and potassium were associated with significant (P.05) gains in whole-body BMD and BMC. Higher intakes of calcium, vitamin D, skim milk, dairy foods, potassium, and a dietary pattern of high dairy and low fat were associated with significant gains in hip BMD.In young female runners, low-fat dairy products and the major nutrients in milk (calcium, vitamin D, and protein) were associated with greater bone gains and a lower stress fracture rate. Potassium intake was also associated with greater gains in hip and whole-body BMD.

Depot medroxyprogesterone acetate (DMPA) is a highly effective progestin-only contraceptive that is widely used by adolescents. We investigated bone mineral density (BMD) changes in female adolescents during and following use of this method.A multicenter, prospective, non-randomized observational study in 98 healthy female adolescents aged 12-18 years who initiated DMPA intramuscular injections for contraception and provided BMD data for up to 240 weeks while receiving DMPA and for up to 300 weeks after DMPA cessation. BMD at the lumbar spine (LS), total hip (TH) and femoral neck (FN) was assessed by dual-energy X-ray absorptiometry. A mixed model analysis of variance was used to examine BMD changes.At the time of their final DMPA injection, participants had mean BMD declines from baseline of 2.7% (LS), 4.1% (TH) and 3.9% (FN) (p.001 at all three sites). Within 60 weeks of discontinuation of DMPA, mean LS BMD had returned to baseline levels, and 240 weeks after DMPA discontinuation, the mean LS BMD was 4.7% above baseline. Mean TH and FN BMD values recovered to baseline values more slowly: 240 weeks and 180 weeks, respectively, after the last DMPA injection.BMD loss in female adolescents receiving DMPA for contraception is substantially or fully reversible in most girls following discontinuation of DMPA, with faster recovery at the LS than at the hip.

To render a diagnosis pediatricians rely upon reference standards for bone mineral density or bone mineral content, which are based on cross-sectional data from a relatively small sample of children. These standards are unable to adequately represent growth in a diverse pediatric population. Thus, the goal of this study was to develop sex and site-specific standards for BMC using longitudinal data collected from four international sites in Canada and the United States. Data from four studies were combined; Saskatchewan Paediatric Bone Mineral Accrual Study (n = 251), UBC Healthy Bones Study (n = 382); Penn State Young Women's Health Study (n = 112) and Stanford's Bone Mineral Accretion study (n = 423). Males and females (8 to 25 years) were measured for whole body (WB), total proximal femur (PF), femoral neck (FN) and lumbar spine (LS) BMC (g). Data were analyzed using random effects models. Bland–Altman was used to investigate agreement between predicted and actual data. Age, height, weight and ethnicity independently predicted BMC accrual across sites (P < 0.05). Compared to White males, Asian males had 31.8 (6.8) g less WB BMC accrual; Hispanic 75.4 (28.2) g less BMC accrual; Blacks 82.8 (26.3) g more BMC accrual with confounders of age, height and weight controlled. We report similar findings for the PF and FN. Models for females for all sites were similar with age, height and weight as independent significant predictors of BMC accrual (P < 0.05). We provide a tool to calculate a child's BMC Z-score, accounting for age, size, sex and ethnicity. In conclusion, when interpreting BMC in pediatrics we recommend standards that are sex, age, size and ethnic specific.

Bone mineral content (BMC) and areal bone mineral density (BMD) have been reported to be lower in Asian than in Caucasian adults. To determine if racial differences in bone mass are present in younger subjects and whether they reflect differences in estimated volumetric bone density or in bone size, we compared measurements of bone mineral in healthy young Asian- and Caucasian-American males and females. Bone mineral was measured at the lumbar spine (L2-L4), femoral neck (FN), and whole body (WB) by dual-energy X-ray absorptiometry (DXA) in 99 Asians (49 females, 50 males) and 103 Caucasians (54 females, 49 males) ages 9-26 years. Results were expressed as BMC, BMD, and apparent density (BMAD), an estimate of volumetric bone density that reduces the effect of bone size. Subjects were compared on the basis of chronological age as well as by Tanner stage to correct for potential differences in the timing of puberty. Habitual dietary intake and physical activity were also assessed and correlated with bone mineral. The Asian and Caucasian cohorts differed in body size, diet, and physical activity. Asian females were shorter than the Caucasian females at all stages of puberty and weighed less at pre-/early puberty (p < 0.05). Asian males were older than Caucasians at midpuberty (p < 0.01) and weighed less than the Caucasian males at pubertal maturity (p = 0.001). Asian youths also consumed less calcium and reported less weight-bearing activity. Racial differences were most apparent when comparing BMC data. Asian males had greater spine BMC at midpuberty and lower WB BMC at maturity (p < 0.05). Asian females had lower FN BMC through midpuberty and lower WB BMC in pre-/early puberty (p < 0.05). WB BMD and WB BMC/height values were significantly lower in mature Asian versus Caucasian males. No significant racial differences in BMAD were observed. Multivariate regression analysis indicated that the differences in BMD and BMAD between Asian and Caucasian subjects were largely attributable to differences in weight and pubertal stage, and, at the FN, in weight-bearing activity. Further, the explanatory variables were less strongly associated with BMAD than with BMD. In summary, no significant differences in BMD were found between Asian and Caucasian youths through midpuberty; however, WB BMD and WB BMC/height values were lower in Asian males at sexual maturity. We conclude that observed differences in bone mineral between Asians and Caucasians may be partially attributed to the smaller bone size of Asians.

Context: As awareness of osteoporosis in childhood has increased, so have pressures to consider use of the pharmacological agents used to treat osteoporosis in adults. This review examines available research on the efficacy and safety of bisphosphonate therapy for pediatric osteoporosis. Evidence Acquisition: We reviewed the medical literature for key articles and consensus statements on the use of bisphosphonates in children through June 2008. Evidence Synthesis: We compared reports using varying bisphosphonate agents, doses, and duration of therapy to treat osteogenesis imperfecta and a variety of secondary causes of osteoporosis in children. Conclusions drawn from a recently published Cochrane analysis and the consensus statements from experts in the field were considered as well. Conclusions: Use of bisphosphonate therapy in pediatric patients remains controversial because of inadequate long-term efficacy and safety data. For this reason, many experts recommend limiting use of these agents to those ch...

Background This analysis was conducted to assess the baseline data and design methodology within an observational longitudinal comparison of use vs. nonuse of the injectable (intramuscular) contraceptive depot medroxyprogesterone acetate (DMPA-IM) and its effect on bone mass in adolescent women. Study Design A prospective, observational, open-label, unmatched-cohort, safety study in females aged 11–18 years. Participants either self-selected DMPA-IM (Depo-Provera®) 150 mg to be administered every 12 weeks for up to 240 weeks with a 120-week post-treatment follow-up or were nonusers (users of nonhormonal contraception or sexually abstinent) who were to be followed up for up to 360 weeks. As each participant entered the study, bone mineral density (BMD) was measured by dual-energy X-ray absorptiometry at the lumbar spine, hip and femoral neck regions, along with total body bone mineral content; serum and urine specimens were obtained for assay of bone metabolism markers and participants' histories of parity and tobacco and alcohol use were obtained. Results A total of 389 participants were enrolled: 169 elected to begin DMPA-IM; 26 chose nonhormonal methods and 194 were abstinent. The baseline characteristics indicated significant disparities between DMPA-IM users and nonusers: compared with the nonusers, DMPA-IM users had more advanced chronologic and gynecologic ages, were more likely to have smoked, been pregnant and included more blacks. These factors would likely influence bone accretion rates independent of DMPA-IM exposure. Comparison of participant BMDs with standard reference data revealed that the study cohorts did not match reference populations closely enough to make a direct between-cohort comparative analysis feasible. Conclusions The baseline differences in cohort characteristics preclude a meaningful comparison of mean BMD changes over time between DMPA-IM users and nonusers cohorts, and comparisons of changes in Z-scores between cohorts were also not appropriate. Therefore, within-participant BMD decreases from baseline were established as safety thresholds, and the proportion of individuals crossing those thresholds on a persistent or progressive basis was identified as the revised primary end point.

KELSEY, J. L., L. K. BACHRACH, E. PROCTER-GRAY, J. NIEVES, G. A. GREENDALE, M. SOWERS, B. W. BROWN JR., K. A. MATHESON, S. L. CRAWFORD, and K. L. COBB. Risk Factors for Stress Fracture among Young Female Cross-Country Runners. Med. Sci. Sports Exerc., Vol. 39, No. 9, pp. 1457–1463, 2007. Purpose: To identify risk factors for stress fracture among young female distance runners. Methods: Participants were 127 competitive female distance runners, aged 18–26, who provided at least some followup data in a randomized trial among 150 runners of the effects of oral contraceptives on bone health. After completing a baseline questionnaire and undergoing bone densitometry, they were followed an average of 1.85 yr. Results: Eighteen participants had at least one stress fracture during follow-up. Baseline characteristics associated (P G 0.10) in multivariate analysis with stress fracture occurrence were one or more previous stress fractures (rate ratio [RR] [95% confidence interval] = 6.42 (1.80–22.87), lower wholebody bone mineral content (RR = 2.70 [1.26–5.88] per 1-SD [293.2 g] decrease), younger chronologic age (RR = 1.42 [1.05–1.92] per 1-yr decrease), lower dietary calcium intake (RR = 1.11 [0.98–1.25] per 100-mg decrease), and younger age at menarche (RR = 1.92 [1.15–3.23] per 1-yr decrease). Although not statistically significant, a history of irregular menstrual periods was also associated with increased risk (RR = 3.41 [0.69–16.91]). Training-related factors did not affect risk. Conclusion: The results of this and other studies indicate that risk factors for stress fracture among young female runners include previous stress fractures, lower bone mass, and, although not statistically significant in this study, menstrual irregularity. More study is needed of the associations between stress fracture and age, calcium intake, and age at menarche. Given the importance of stress fractures to runners, identifying preventive measures is of

On April 14, 2005, a workshop on the skeletal effects of pharmacologic agents in children was held at the National Institutes of Health. Jointly sponsored by the American Society for Bone and Mineral Research (ASBMR) and the National Institute of Child Health and Human Development, the meeting was organized in response to suggestions from the Pediatric Bone Initiative of the ASBMR.1 Previous discussions at the 2003 ASBMR symposium on the state of pediatric bone research1 led to the conclusion that there was a lack of information on the effects of Food and Drug Administration–approved therapeutic agents on bone in children. Advances in pediatric medicine have produced a new population of children who are able to live into adulthood with chronic illnesses and were previously thought to have a poor prognosis for survival beyond their childhood years. Medications and direct effects of illness may compromise normal bone mineralization, leading to skeletal deformities and osteopenia at a relatively young age. Several topics discussed at the 2003 ASBMR symposium were further examined and developed in the recent National Institutes of Health workshop, such as the limitations of currently available pediatric bone density–reference data, the challenges of measuring bone mass and strength in children, clinical-trial design, chronic drug effects on growing bone, and therapeutic agents for pediatric bone disorders. The following is a summary of all the presentations from the National Institutes of Health workshop on pediatric bone. Detailed summaries of selected talks are provided as well. The first session provided basic background on normal bone accrual in children, the regulation of skeletal growth, and the effects of calcium, phosphorus, and vitamin D on growing bone. Dr Jeffrey Baron and his co-workers2,3 reviewed the role of the growth plate in linear skeletal growth and work from his own laboratory … Address correspondence to Gordon L. Klein, MD, MPH, University of Texas Medical Branch, Department of Pediatrics, 301 University Blvd, Galveston, TX 77555-0352. E-mail: gklein{at}utmb.edu

During adolescence, bone formation prevails over resorption, resulting in accumulation of 40% of peak bone mass throughout this time period. Although multiple studies have explored bone mass accrual during the early stages of puberty, less is known about factors that may influence bone accrual during later years of adolescence. In the present cross-sectional study we examined relationships among bone mineral density (BMD) and demographic factors, behavioral variables, and bone metabolism markers in postmenarchal adolescent girls.The population was comprised of 389 healthy postmenarchal adolescent girls aged 11-18 years, who were recruited into a prospective study of the effect of depot medroxyprogesterone acetate (DMPA) on bone health in adolescents. At the baseline visit, investigators collected demographic, reproductive health, and lifestyle data, and performed a complete physical examination. Body mass index (BMI) was calculated. Before study initiation, BMD at the lumbar spine, total hip, and femoral neck was measured by dual-energy X-ray absorptiometry (DXA), and markers of bone metabolism (serum bone-specific alkaline phosphatase [BAP], serum osteocalcin, and urinary N-telopeptide [uNTX]) were measured. The baseline data from this study were analyzed to evaluate possible correlates of BMD in postmenarchal adolescent girls. Potential associations between BMD values and other parameters were assessed by analysis of variance and Pearson's correlation coefficient.Participants enrolled in the study had a mean (+/- SD) chronological age of 14.9 +/-1.7 years (range 11-18), mean gynecologic age of 39.9 +/-23.0 months (range 1-120) postmenarche, and mean BMI of 23.5 +/-4.6 kg/m(2) (range 16.0-42.2). Racial/ethnic distribution was 46% African American, 35% Caucasian, and 19% other races; 9% had previously been pregnant. Positive correlations were observed between lumbar spine BMD and chronological age (r = .301, p.0001), gynecologic age (r = .349, p.0001), and BMI (r = .371, p.0001). Total hip and femoral neck BMD values were significantly higher (p.05 and p.05, respectively) in African American participants compared with non-African American participants. Previous history of pregnancy was significantly associated with a lower BMD at the lumbar spine (p.0001) and the total hip (p.01) when compared with the BMD of adolescents who had never been pregnant. Cigarette smoking and alcohol use were not associated with significant differences in BMD. Negative correlations were observed between gynecologic age and the levels of BAP (r = -.564, p.0001), osteocalcin (r = -.349, p.0001), and uNTX (r = -.281, p.0001), and between lumbar spine BMD and BAP (r = -.363, p.0001), osteocalcin (r = -.129, p.05), and uNTX (r = -.202, p.001) levels.Our data demonstrate that chronological age, gynecologic age, race/ethnicity, BMI, and previous history of pregnancy are markedly associated with BMD in postmenarchal adolescent girls. Bone accretion in the postmenarchal years continues in the face of a slowdown in bone turnover during this time period.

Background Primary ovarian insufficiency (POI) is characterized by 4 to 6 months of amenorrhea and elevated serum FSH and LH in females less than 40 years. Ovarian insufficiency is uncommon in pediatrics and typically results from a chromosomal abnormality or treatment for malignancy. Idiopathic POI in which no apparent precipitant is identified is even rarer. After encountering three teens with idiopathic POI in recent months, we utilized an informatics-enabled search of the electronic medical records from our hospital to identify all cases of idiopathic POI presenting from 1998–2013. Cases presentation 15 girls (ages 14.4 to 17.9 years) met criteria for idiopathic POI. At diagnosis, breast development ranged from Tanner stage 1 to 5; 6 of 15 patients had secondary amenorrhea. All patients presented in the past 11 years and 13 of 15 in the past 5 years. Conclusions In this first case series of POI from the United States, we observed a clustering at our institution in recent years. If an increased incidence of idiopathic POI is identified at other institutions, further investigation into potential environmental and genetic precipitants is warranted.

Bone densitometry is used to assess skeletal health in clinical and research settings, with the goal of achieving reproducible measurements of bone mass that help to identify individuals predisposed to fracture. The search is now on for better methods of capturing additional factors that contribute to bone strength, including bone size, geometry, microarchitecture, and turnover rates. This has proved particularly challenging in growing children, whose bones continually change in size, shape, and mass. Dual energy X-ray absorptiometry is the preferred method for measuring bone mass in children, but the technique has several limitations, and interpreting the findings can be problematic. Peripheral quantitative computed tomography is a promising method for assessing bone mass and other indices correlating with bone strength, but a lack of precision and paediatric norms currently restricts its clinical utility. Although bone mineral density is predictive of future fracture risk in adults, the evidence in children is less conclusive, and a diagnosis of osteoporosis in a child should not be made on densitometric findings alone. Developing a clearer understanding of how measures of bone mass and strength correlate with bone fracture in children will help target preventive strategies for those in greatest need.

Although obesity is associated with increased risk of many chronic diseases including cardiovascular disease, diabetes, hypertension, and cancer, there is little evidence to suggest that obesity increases risk of osteoporosis. In fact, both weight and body mass index (BMI) are positive predictors of bone mass in adults, suggesting that those who are overweight or obese may be at lower risk of osteoporosis. However, recent evidence suggests that in children and adolescents, obesity may be associated with lower rather than higher bone mass. To understand the relation of fat mass to bone mass, we examined data gathered from an ethnically diverse group of 921 young women, aged 20-25 years (317 African Americans, 154 Asians, 322 Caucasians, and 128 Latinas) to determine how fat mass (FM) as well as lean tissue mass (LTM) is associated with bone mass. Bone mass, FM, and LTM were measured using dual energy X-ray absorptiometry (GE Lunar Corp, Madison, WI). Bone mass was expressed as bone mineral density (BMD; g/cm2) and bone mineral apparent density (BMAD; g/cm3) for the spine and femoral neck, and as BMD and bone mineral content (BMC; g) for the whole body. Regression techniques were used to examine the following: (1) in separate equations, the associations of LTM and FM with each bone mass parameter; and (2) in the same equation, the independent contributions of LTM and FM to bone mass. LTM and FM were positively correlated with BMD at all skeletal sites. When the contributions of FM and LTM were examined simultaneously, both FM and LTM continued to be positively associated with bone mass parameters but the effect of FM was noted to be smaller than that of LTM. We conclude that in young women, LTM has a greater effect than fat mass on bone density per kg of tissue mass.

Cystic fibrosis (CF) is the most common genetic disease within the Caucasian population and leads to premature respiratory failure. Approximately 60,000 individuals are currently living with CF in North America and Europe, 40% of whom are adults. Thelifespanofthesepatientshasincreasedfromapproximately 2 to 32 yr of age over the last three decades. Bone disease has emerged as a common complication in long-term survivors of CF. Some studies have observed that 50–75% of adults have low bone density and increased rates of fractures. Prevention and treatment of CF-related bone disease must address the myriad risk factors (decreased absorption of fat-soluble vitamins due to pancreatic insufficiency, altered sex hormone production, chronic lung infection with increased levels of bone-active cytokines, physical inactivity, and glucocorticoid therapy) for poor bone health. This review is a condensed and updated summaryoftheGuidetoBoneHealthandDiseaseinCysticFibrosis: A Consensus Conference, a statement that evolved from a meeting convened by the Cystic Fibrosis Foundation in May 2002 to address the pathogenesis, diagnosis, and treatment of bone disease in CF. The goal of this conference was to develop practice guidelines for optimizing bone health in patients with CF. (J Clin Endocrinol Metab 90: 1888–1896, 2005)

Duchenne muscular dystrophy is the most frequently occurring of the childhood muscular dystrophies and is inherited as an X-linked recessive disorder [1–3]. Bone health is frequently compromised and fractures are more common in this patient population [4–11]. Fractures impact negatively on their quality of life and may contribute to the loss of ambulation [4,5]. The goals of this workshop were to

The Canadian Panel of the International Society for Clinical Densitometry has developed standards in order to establish the minimum level of acceptable performance for the practice of bone densitometry in Canada. Previously, this group addressed the performance of densitometry in postmenopausal women. This report addresses the use of densitometry in men, premenopausal women, and children with a focus on dual-energy X-ray absorptiometry.

BACKGROUND Reduced bone mass and fragility fractures are known complications after transplantation in adults. Far less is known about the skeletal effects of transplantation in children and adolescents. METHODS This cross-sectional study examined the skeletal status of children (ages 9-18 years) who were at least 1 year post-cardiac (n=13), post-renal (n=8), or post-bone marrow (BMT; n=15) transplantation. Bone mass at total hip, femoral neck, spine (L2-4), and whole body (WB) was determined by dual energy x-ray absorptiometry and compared with age, sex, and ethnic-specific reference data. Standard deviations (z-scores) were calculated for both areal bone mineral density (BMD) and estimated volumetric bone density (bone mineral apparent density [BMAD]). RESULTS Cardiac transplant patients had significantly lower BMD z-scores compared with the reference population at all skeletal sites. BMT recipients had significantly reduced BMD z-scores at total hip, spine, and WB. Kidney transplant patients had a significantly reduced WB BMD z-score only. Spine BMAD z-scores remained significantly reduced in cardiac and BMT subjects. Three of 36 patients had radiographic evidence of spinal fracture after transplantation. No correlation between steroid dosage and any measure of bone mass was observed. CONCLUSIONS Cardiac and BMT recipients had reduced BMD at multiple skeletal sites, and renal transplant recipients had reduced WB BMD for age. Deficits in spine bone density persisted after correcting for small bone size using BMAD. Low bone density and the occurrence of vertebral fractures indicate that cardiac, renal, and bone marrow transplantation in children is associated with reduced bone health.

COBB, K. L., L. K. BACHRACH, G. GREENDALE, R. MARCUS, R. M. NEER, J. NIEVES, M. F. SOWERS, B. W. BROWN, JR., G. GOPALAKRISHNAN, C. LUETTERS, H. K. TANNER, B. WARD, and J. L. KELSEY. Disordered Eating, Menstrual Irregularity, and Bone Mineral Density in Female Runners. Med. Sci. Sports Exerc., Vol. 35, No. 5, pp. 711–719, 2003. Purpose: To examine the relationships between disordered eating, menstrual irregularity, and low bone mineral density (BMD) in young female runners. Methods: Subjects were 91 competitive female distance runners aged 18 –26 yr. Disordered eating was measured by the Eating Disorder Inventory (EDI). Menstrual irregularity was defined as oligo/amenorrhea (0 –9 menses per year). BMD was measured by dual x-ray absorptiometry. Results: An elevated score on the EDI (highest quartile) was associated with oligo/amenorrhea, after adjusting for percent body fat, age, miles run per week, age at menarche, and dietary fat, (OR [95% CI]: 4.6 [1.1–18.6]). Oligo/amenorrheic runners had lower BMD than eumenorrheic runners at the spine (5%), hip (6%), and whole body (3%), even after accounting for weight, percent body fat, EDI score, and age at menarche. Eumenorrheic runners with elevated EDI scores had lower BMD than eumenorrheic runners with normal EDI scores at the spine (11%), with trends at the hip (5%), and whole body (5%), after adjusting for differences in weight and percent body fat. Runners with both an elevated EDI score and oligo/amenorrhea had no further reduction in BMD than runners with only one of these risk factors. Conclusion: In young competitive female distance runners, (i) disordered eating is strongly related to menstrual irregularity, (ii) menstrual irregularity is associated with low BMD, and (iii) disordered eating is associated with low BMD in the absence of menstrual irregularity. Key Words: FEMALE ATHLETES, LONG DISTANCE, OSTEOPENIA, OSTEOPOROSIS, AMENORRHEA, OLIGOMENORRHEA, EATING ATTITUDES, EATING DISORDER INVENTORY, FEMALE ATHLETE TRIAD

The optimal method to assess pediatric bone mass remains controversial. Dual X-ray absorptiometry (DXA) is used most commonly for clinical assessments in children, but calcaneus ultrasound (CUS) is less costly, is free of ionizing radiation, and predicts fracture as well as DXA in adults. This study was designed to compare CUS and DXA in 42 young patients (ages 9-21) with chronic disease and/or fragility fractures. Zscores for broadband ultrasound attenuation (BUA) and speed of sound (SOS) determined using the Lunar Achilles Plus ultrasonometer were compared with Z-scores for areal bone mineral density (BMD) and volumetric BMD using DXA (Hologic). Logistic regression was employed to predict low bone density measured by DXA (defined as spinal BMD Z-score-2) from CUS measurements. Sensitivity/specificity analysis was performed to compare CUS and spinal DXA Z-scores as predictors of previous low-impact fracture. Correlations between CUS and DXA Z-scores were in the range of r = 0.3-0.6. Areas under the receiver operator characteristic (ROC) curves for BUA and SOS predicting low bone density by DXA were similar: 0.81 and 0.82, respectively. ROC curve areas for spinal DXA, BUA, and SOS predicting previous fracture were also similar: 0.85, 0.84, and 0.84, respectively. While CUS correlates only modestly with DXA, ROC curve areas indicate that CUS detects low bone mineral in children with fragility fractures as well as DXA and may be a viable initial screen for osteopenia.

Background An average daily calcium intake of 1300 mg is recommended for North American adolescents aged 9-18 y. However, questions remain about these recommendations. Objective We assessed whether there is a stage of puberty when dietary calcium is more strongly related to peak bone mass, as indicated by young adult bone mass (YABM); whether dietary calcium intake > 1000 mg/d in adolescence is associated with higher YABM; and whether race affects any of these associations between dietary calcium and YABM. Secondarily, we evaluated relations between sedentariness and YABM. Design In a retrospective cohort study, we recruited 693 black and white women aged 21-24 y who had participated in the 10-y National Heart, Lung, and Blood Institute Growth and Health Study and measured YABM with the use of dual-energy X-ray absorptiometry. Dietary calcium and sedentary activity data, gathered through 3-d food records and self-reports of television-video viewing at 8 annual examinations, were averaged over 3 pubertal stages. Complete data were available from 161 black and 180 white females. Multiple regression, controlling for race, weight, and height, was applied to assess diet and activity relations with YABM. Results Dietary calcium was most strongly associated with YABM in midpuberty. Calcium intake > 1000 mg/d was associated with higher YABM, but this association was not significant at all skeletal sites. Race did not affect the observed relations between calcium and YABM. Sedentary activity in prepuberty was inversely associated with YABM. Conclusions Interventions should focus on ensuring adequate calcium intake in midpuberty and on minimizing sedentariness in prepuberty.

Purpose Vitamin D deficiency and cardiometabolic risk factors are common in obese adolescents. Observational studies demonstrate an inverse relationship among serum 25-hydroxyvitamin D (25OHD) and obesity, insulin resistance, and inflammatory cytokines. This pilot study explores if vitamin D supplementation could reduce serum concentrations of inflammatory cytokines (interleukin [IL] 6, IL-10, tumor necrosis factor α), adiponectin, lipids, hemoglobin A1C, and high-sensitivity C-reactive protein (hs-CRP). A secondary aim was to determine the associations between baseline serum 25OHD concentrations and body mass index (BMI), hs-CRP, inflammatory cytokines, and lipids. Methods Overweight and obese adolescents enrolled in this 24-week, randomized, double-blind study were given 150,000 IU ergocalciferol or placebo at baseline and 12 weeks. Outcome measurements included serum 25OHD, inflammatory cytokines, adiponectin, hs-CRP, lipids, hemoglobin A1C, and BMI at baseline, 12, and 24 weeks. Results Of 40 participants, 31 (78%) completed the study. Mean ± standard error 25OHD levels were similar in vitamin D and placebo groups at baseline (19.6 ± 5.3 vs. 25.8 ± 10.8 ng/mL) and 24 weeks (20.1 ± 3.4 vs. 24.6 ± 8.4 ng/mL). Inflammatory and cardiovascular markers were not significantly different between groups at 24 weeks. Serum 25OHD at baseline was associated with BMI ( r = −.44 [95% confidence interval, −.66 to −.15]) but not with other outcome measures. Conclusions Supplementation with vitamin D at 150,000 IU every 3 months failed to increase serum 25OHD or alter inflammatory markers and lipids in overweight and obese youth. Further studies are needed to establish the dose of vitamin D required to increase 25OHD and determine potential effects on metabolic risk factors in obese teens.

Progress toward identifying and treating disorders of bone fragility in pediatric patients has been considerable in recent years. This article will summarize several key advances in the management of osteoporosis in children and adolescents.Recommendations from the 2013 pediatric Position Development Conference provide expert guidance for evaluating bone health in younger patients. The diagnosis of pediatric osteoporosis can be made in a child with low-trauma vertebral fractures or a combination of low bone mass and long bone fractures. Management of bone fragility includes optimizing nutrition, activity, and treatment of the underlying disease. Pharmacologic agents can be considered if these measures fail to prevent further bone loss or fractures. Although the efficacy and safety of several intravenous and oral bisphosphonates have been examined, there is still no consensus on the optimal drug, dose, or duration of treatment. Observational studies of children with secondary osteoporosis provide insight into risk factors for fracture or the potential for recovery.Despite advances in the diagnosis and treatment of pediatric osteoporosis, more research is needed. Randomized controlled trials of pharmacologic agents should be defined to target those identified at the highest risk by observational studies.http://links.lww.com/COE/A9

The International Society for Clinical Densitometry Official Revised Positions on reporting of densitometry results in children represent current expert recommendations to assist health care providers determine which skeletal sites should be measured, which, if any, adjustments should be made, reference databases to be used, and the elements to include in a dual-energy X-ray absorptiometry report. The recommended scanning sites remain the total body less head and the posterior-anterior spine. Other sites such as the proximal femur, lateral distal femur, lateral vertebral assessment, and forearm are discussed but are only recommended for specific pediatric populations. Different methods of interpreting bone density scans in children with short stature or growth delay are presented. The use of bone mineral apparent density and height-adjusted Z-scores are recommended as suitable size adjustment techniques. The validity of appropriate reference databases and technical considerations to consider when upgrading software and hardware remain unchanged. Updated reference data sets for all contemporary bone densitometers are listed. The inclusion of relevant demographic and health information, technical details of the scan, Z-scores, and the wording "low bone mass or bone density" for Z-scores less than or equal to -2.0 standard deviation are still recommended for clinical practice. The rationale and evidence for the development of the Official Positions are provided. Changes in the grading of quality of evidence, strength of recommendation, and worldwide applicability represent a change in current evidence and/or differences in opinion of the expert panelists used to validate the position statements for the 2013 Position Development Conference.

Pediatric renal transplantation recipients have numerous risk factors for decreased bone mass, including the underlying renal disease, nutritional deficits, decreased physical activity, inflammation and exposure to steroid therapy. The assessment of bone mineralization in children following renal transplantation is fraught with difficulty. Dual energy x-ray absorptiometry (DXA) is the most commonly employed tool to assess bone mineralization. However, DXA has important limitations in children and in individuals with renal disease. This brief review will examine the expected gains in bone size and bone mass during growth and the mechanisms by which renal failure and steroid therapy interrupt these process. In addition, the limitations of DXA for detecting impaired bone mineralization in children with renal disease are reviewed and alternative approaches explored.

We examined age-related changes in quantitative ultrasound of the calcaneus in 311 healthy males and females ages 6.6–20 yr using the Lunar Achilles ultrasound device. This equipment has been adapted for pediatric use with the provision of shims designed to properly position smaller feet relative to the transducers. Broadband ultrasound attenuation (BUA) (decibels/megahertz), speed of sound (SOS) (meters/second), and stiffness index (SI) (percent) increased across the age range until a plateau was reached at 16–18 yr. BUA increased by 40%, SOS by 4%, and SI by 80% across this age range. There was no gender difference in age-related gains. Age, weight, height, and hours of weight-bearing physical activity were all significantly associated with BUA, SOS, and SI. After controlling for age and weight, hours of weight-bearing physical activity showed little to no additional effect on these parameters. Short-term in vivo precision using this device was similar in children to that observed in adults in our laboratory; coefficients of variation for between-day measurements were 1.8, 0.6, and 3.2% for BUA, SOS, and SI, respectively. These data support the feasibility of using the Lunar Achilles in evaluating pediatric bone mass. The ability of this technique to discriminate between osteopenic and normal children remains to be determined.

Peak bone mass (PBM), which is achieved by early adulthood, is a key determinant of the lifetime risk of osteoporosis. Because the foundation for skeletal health is established so early in life, osteoporosis prevention begins by optimizing gains in bone mineral throughout childhood and adolescence. Heritable factors account for an estimated 60–80% of the variability in PBM, with diet, physical activity and hormonal status serving as important modifiers of bone accrual. Recent pediatric studies have clarified the tempo and magnitude of gains in bone mineral and the modulating effects of diet, activity and sex steroids. The challenge lies in designing effective means to reverse trends of decreased calcium consumption, increased sodium intake and diminished physical activity among children and adolescents. Equally important is raising the awareness of health care providers to recognize children at risk for suboptimal acquisition of PBM.

Purpose: To assess how commonly hormone replacement therapy (HRT) and other measures are prescribed for the treatment of osteopenia in children and adolescents with anorexia nervosa (AN). Methods: A self-administered questionnaire was distributed and completed by allopathic and osteopathic physician members of the Society for Adolescent Medicine at its 1998 annual meeting. The questionnaire was also mailed and E-mailed between March 1998 and February 1999. Descriptive statistics included percentages and measures of central tendency. Results: The questionnaire was completed by 394 of the 1029 physicians surveyed (38.3%). Of the 268 respondents who treated patients with AN under the age of 18 years, 77.6% prescribed HRT. The decision to prescribe HRT was influenced by patient's age but not by bone mineral status. Among those who prescribed HRT, additional therapies included increased caloric intake (89.4%), weight gain (82.2%), increased calcium intake (84.1%), a change in exercise patterns (59.1%), and vitamin D supplementation (37.0%). Only 59 (22.0%) did not use HRT as a treatment modality. One-third of nonprescribers cited the lack of evidence of efficacy of HRT in preventing osteopenia. More recent medical graduates were less likely to prescribe HRT. Conclusions: This survey suggests that practitioners caring for adolescent females with AN commonly prescribe HRT for the treatment of osteopenia despite the paucity of evidence demonstrating that it effectively prevents or reverses bone loss associated with this disorder.

Ethnic and gender differences in bone mineral acquisition were examined in a longitudinal study of 423 healthy Asian, black, Hispanic, and white males and females (aged 9-25 yr). Bone mass of the spine, femoral neck, total hip, and whole body was measured annually for up to 4 yr by dual energy x-ray absorptiometry. Age-adjusted mean bone mineral curves for areal (BMD) and volumetric (BMAD) bone mineral density were compared for the 4 ethnic groups. Consistent differences in areal and volumetric bone density were observed only between black and nonblack subjects. Among females, blacks had greater mean levels of BMD and BMAD at all skeletal sites. Differences among Asians, Hispanics, and white females were significant for femoral neck BMD, whole body BMD, and whole body bone mineral content/height ratio, for which Asians had significantly lower values; femoral neck BMAD in Asian and white females was lower than that in Hispanics. Like the females, black males had consistently greater mean values than nonblacks for all BMD and BMAD measurements. A few differences were also observed among nonblack male subjects. Whites had greater mean total hip BMD, whole body BMD, and whole body bone mineral content/height ratio than Asian and Hispanic males; Hispanics had lower spine BMD than white and Asian males. The tempo of gains in BMD varied by gender and skeletal site. In females, total hip, spine, and whole body BMD reached a plateau at 14.1, 15.7, and 16.4 yr, respectively. For males, gains in BMD leveled off at 15.7 yr for total hip and at age 17.6 yr for spine and whole body. Black and Asian females and Asian males tended to reach a plateau in BMD earlier than the other ethnic groups. The use of gender- and ethnic-specific standards is recommended when interpreting pediatric bone densitometry data.