Children and adolescents with chronic health conditions often face special challenges in keeping themselves healthy, even in areas that aren’t related to their specific illness.
This includes bone health.
Childhood is a critical period when it comes to building healthy bones.
The bones in our body are continuously changing, with new bone being made and old bone being broken down.
In children and young adults, the body makes new bone faster than it breaks down old bones, resulting in an increase in total bone mass.
Most people will reach their peak bone mass by 30 years of age.
After that, our body starts to gradually lose more bone than it builds, resulting in reduced bone mass and increased risk of osteoporosis.
Osteoporosis is a condition where the bones become weak and fragile, making them easy to fracture (break).
The risk of developing osteoporosis depends on how much bone mass the body attains by young adulthood and how fast the body loses it after that.
The more bone mass the body has acquired, the more reserve it has, making it less likely to develop osteoporosis.
Hence, early intervention during childhood, especially during puberty, is critical to maximise peak bone mass while the bones are still “growing”.
This is essential to reduce osteoporosis and fractures later in life.
It’s also important to note that osteoporosis usually occurs in the elderly, but it can also affect children, especially those with chronic health problems.
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Risking the bones
Several risk factors can result in poor bone health in children with chronic health conditions. They include:
Children who are not well are often not physically active, e.g children with cerebral palsy or muscular dystrophy who are bedridden or wheelchair-bound.
Similarly, children who are not able to bear weight will develop weak muscles and bones, which are prone to fractures.
Some medications can affect bone density and strength if taken in large amounts or for a long period of time.
For example, glucocorticoid, which is a steroid medication, can affect bone mass by reducing intestinal calcium absorption and increasing urine calcium excretion.
Certain groups of anti-convulsants, which are medications to control seizures in children with epilepsy, affect vitamin D metabolism, which is needed for calcium absorption.
Some medical conditions or their treatments may affect the body’s ability to absorb and use nutrients, leading to insufficient vital nutrients like calcium, vitamin D and other minerals essential for bone development.
Such conditions include malabsorption, coeliac disease, cystic fibrosis, liver disease and eating disorders such as anorexia nervosa.
Children with health problems often also have reduced appetite and intake.
In addition, their body might require more calories and have increased energy demands.
Certain health conditions themselves might directly affect bone health through chronic inflammation, e.g cancer, inflammatory bowel disease (IBD) or rheumatological conditions such as juvenile idiopathic arthritis and systematic lupus erythematosus.
Being ill for a long time can disrupt hormonal balances that are crucial for bone growth and strength.
Hormones such as growth hormone and sex hormones during puberty, play a significant role in bone health.
Chronic ill health can result in delayed puberty, affecting the normal secretion of these hormones.
Hyperthyroidism (excess thyroid hormones) is also a risk for osteoporosis.
Prevention and intervention
Parents and healthcare providers all play a major role in optimising bone health in these children.
Addressing modifiable risk factors for good bone health throughout childhood is essential, knowing that peak lifetime bone mass is achieved by young adulthood.
Critical factors include good health, a healthy lifestyle, enough vitamin D and calcium intake, and puberty.
Chronic health conditions can create multiple risks for blunted bone accrual and reduced adult bone mass, increasing lifelong risk of fractures.
Children should have sufficient intake of calcium, vitamin D and other nutrients, whether through diet or supplements.
Vitamin D is essential for strong bones as calcium can only be absorbed by the body when vitamin D is present.
The current recommendations for vitamin D are 400 international units (IU) per day for infants younger than 12 months, and 600 IU for children/adolescents.
The main source of vitamin D is sunlight, or fortified milk, yoghurt or cereals.
Children with chronic illness or who have low vitamin D levels may require additional supplementation and monitoring of their vitamin D levels.
This should be discussed with the paediatrician or paediatric endocrinologist.
Appropriate exercise or physical therapy to promote bone strength without worsening the underlying medical condition is encouraged.
It is important for the child to do activities that require them to bear weight, but in a safe manner in order to avoid falls and fractures.
A team consisting of a rehabilitation specialist, physiotherapist and occupational therapist could aid in this endeavour.
Regular monitoring and assessment of risk factors by a paediatric endocrinologist are important.
Periodic blood tests, including for the levels of body minerals and vitamin D, as well as spine X-rays or bone density scans, may be required to enable proactive intervention.
Some cases may require specialised medication to increase bone density, e.g bisphosphonate.
Any hormonal problems, e.g in relation to growth hormone or thyroid hormone levels, or puberty, must also be addressed.
Providing education and support to children and their families about the importance of bone health and measures to prevent or treat are crucial.
Awareness among healthcare providers is important for appropriate early intervention and specialist referral.
Bone health in children is often overlooked as the impact might only be more obvious during adulthood.
Osteoporosis in children is also often a silent disease.
Some children who have experienced fractures of the vertebrae (bones that support the spine) might not experience pain until their condition is severe.
Healthcare providers specialising in paediatrics, endocrinology, nutrition and rehabilitation need to work together to address the specific bone health needs of children with chronic diseases.
Individualised management plans to treat the underlying medical condition and bone health is essential for the overall well-being of the child.
Dr Jeanne Wong Sze Lyn is a consultant paediatrician and paediatric endocrinologist. This is the 12th article in a monthly series called Hormones and Kids. For more information, email starhealth@thestar.com.my. The information provided is for educational purposes only and should not be considered as medical advice. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.
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