Osteoporosis due to glucocorticoid use in children with chronic illness

Osteoporosis is increasingly recognized as a complication of chronic childhood illnesses, particularly when glucocorticoids (GCs) are necessary for treatment. Elucidation of the mechanisms leading to bone fragility in these settings requires disentanglement of the relative contributions of myriad risk factors, including disease activity, muscle weakness, immobilization, delayed growth and puberty, compromised nutrition, and osteotoxic medications. Over the years, bone mass and density evaluations by dual energy X-ray absorptiometry (DXA) have become popular for assessing bone health in children; however, such measurements are difficult to interpret because of the confounding effect of bone size and the lack of DXA-based densitometric criteria for defining osteoporosis in childhood. Recently, a new diagnostic approach for evaluation of densitometric data in children has been suggested, driven by Frost's mechanostat theory. A diagnostic algorithm based on the mechanostat theory of bone-muscle development is proposed for the characterization of bone disease in children with chronic illness. In addition to DXA-based assessments, techniques such as peripheral quantitative computerized tomography and ilial histomorphometry, for which there are pediatric reference data, are gaining ground in the characterization of skeletal changes due to chronic illness. Although these diagnostic techniques expand our understanding of osteoporosis in children, they do not replace clinical assessment. Concrete clinical evidence for GC-induced bone fragility can be seen in spinal changes due to vertebral compression, with spinal morphometry emerging as an essential, but frequently overlooked, tool in the evaluation of children's bone health. Presently, osteoporosis treatment in the chronic illness setting remains experimental and should be restricted to clinical studies. Following an understanding of the natural history of GC-induced osteoporosis in children, randomized, placebo-controlled prevention and intervention trials will be the next step toward the development of clinical practice guidelines.     

Consensus and Controversy Regarding Osteoporosis in the Pediatric Population

ObjectiveTo review current consensus and controversy surrounding the diagnosis and treatment of osteoporosis in childhood and adolescence.MethodsThe medical literature was reviewed with emphasis on the importance of early skeletal health, risk factors for bone fragility, and the diagnosis and management of children at risk for osteoporosis.ResultsChildhood and adolescence are critical periods for optimizing bone growth and mineral accrual. Bone strength is determined by bone size, geometry, quality, and mass—variables that are influenced by genetic factors, activity, nutrition, and hormones. For children with genetic skeletal disorders or chronic disease, bone growth and mineral accrual may be compromised, increasing the lifetime risk of osteoporosis. The goal for the clinician is to identify children at greatest risk for future fragility fracture. Bone densitometry and turnover markers are challenging to interpret in children. Prevention and treatment of bone fragility in children are less well established than in adults. Optimizing nutrition and activity may not restore bone health, but the drug armamentarium is limited. Sex steroid replacement has not proven effective in restoring bone mass in patients with anorexia nervosa or exercise-associated amenorrhea. Bisphosphonates can increase bone mass and may reduce bone pain and fractures, most convincingly in patients with osteogenesis imperfecta. Further studies are needed to establish the safety, efficacy, and optimal drug, duration, and dosage in pediatric patients.ConclusionBone health during the first 2 decades contributes to the lifetime risk of osteoporosis. Further research is needed to develop evidence-based recommendations for the diagnosis and treatment of osteoporosis in childhood. (Endocr Pract. 2007;13:513-520)     

Chronic illness and functional limitation in Ontario children: findings of the Ontario Child Health Study.

The Ontario Child Health Study (OCHS) was based on interviews of 1869 Ontario families who were selected by means of a stratified, multistaged sampling method from the 1981 census of Canada. Its primary purpose was to determine the prevalence and distribution of mental health problems in Ontario children aged 4 to 16 years and their families, but it also allowed an estimate of other significant medical conditions and provided an overview of these children''s use of health care, education and social services. Our results are based on questionnaire responses concerning 3294 children. Limitation of function without a chronic illness or medical condition was reported in 1.9%, the converse in 14.0%, and a chronic illness or medical condition with limitation of function in 3.7%. When the three groups are considered together, 19.6% of Ontario children had a chronic health problem. Children of lower socioeconomic status were much more likely to have chronic health problems. Overall, children with chronic health problems were more likely to use physician, special education, social and mental health services. These findings have implications for those who provide services for children, plan community programs or train professionals in caring for children.     

Phenolic phytochemicals and bone

Concerning the prevention of osteoporosis, recognized as a major public health problem, nutrition may appear as an alternative strategy for optimizing health skeleton. The importance of adequate calcium and vitamin D intakes for bone health is now well documented. But, in addition to essential macro- and micronutrients, human diet contains a complex array of non-nutrient natural bioactive molecules, namely the phytochemicals that may act and protect bone. Among phytochemicals, emphasis has been so far placed upon polyphenols. Indeed, subsequent epidemiological studies have suggested associations between long-term consumption of diets rich in polyphenols and protection against chronic diseases. With respect to human health, flavonoids are the most extensively studied polyphenols. These compounds may be partly responsible for some of the positive links found between fruit and vegetables intake and higher bone mineral density in adults and children. However, no long-term intervention studies in humans have investigated the effect of specific phenolic phytochemicals on the prevention of bone loss in postmenopausal women, except for phytoestrogens (soy isoflavones, lignans). Besides, in animal models of postmenopausal osteoporosis, consumption of some dietary flavonoids has been shown to prevent ovariectomy-induced bone loss. Finally, few in vitro experiments with bone cells have reported cellular and molecular mechanisms of phytochemicals involved in bone metabolism. To date, investigations providing some evidence of a positive impact of some phytochemicals on bone metabolism are accumulating but further studies, notably clinical trials, are needed to explore the various bioactivities offered by such compounds. Anyway, it can be postulated that increased consumption of plant-derived foods, especially fruit and vegetables, may be positive in the prevention of osteoporosis.     

Unmet need for additional medical care for sick children in mother's view in rural Bangladesh: implications for improving child health services

While a country's health policy aims to provide health services to all who need them, very little in known about unmet need for additional medical care from users' perspectives in Bangladesh. This study examined unmet medical need (defined as whether a mother felt that, to manage sickness, her child had required medical care that was not available, regardless of reasons and medical care sought) of 2123 under-15 sick children by illness and child's socioeconomic characteristics in rural Bangladesh. The 1996 Health and Socioeconomic Survey conducted in Matlab recorded children's chronic (a disease or a condition lasting 3 months or more) and acute (a disease or a condition with a rapid onset and a short, severe course) morbidity, medical care sought to combat illness and unmet needs for additional medical services in mothers' views to manage the illness. The survey also recorded household socioeconomic data. Logistic regression was used to examine the data. The results reveal that unmet needs for additional medical care were 5.4% for children with acute illnesses, and 30.2% for children with chronic illnesses. For chronic illnesses, seeking medical care to manage illness from any health provider outside the home reduced unmet medical needs. Economic inequalities existed for both acute and chronic illnesses: the odds ratio of unmet medical needs for sick children of the least poor households was 0.42 (95% CI: 0.28-0.64) times that for sick children of the very poor households. The critically high unmet needs for children's chronic morbidity reveal that the chronic disease control programme in Bangladesh needs urgent revisiting and strengthening.     

Measuring bone mass in children: can we really do it?

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.     

Latino children's health and the family-community health promotion model

A majority of Latino children in the US live in poverty. However, unlike other poor children, Latino children do not seem to have a consistent association between poverty and poor health. Instead, many poor Latino children have unexpectedly good health outcomes. This has been labeled an epidemiologic paradox. This paper proposes a new model of health, the family-community health promotion model, to account for this paradox. The family-community health promotion model emphasizes the family-community milieu of the child, in contrast to traditional models of health. In addition, the family-community model expands the outcome measures from physical health to functional health status, and underscores the contribution of cultural factors to functional health outcomes. In this paper, we applied the family-community health promotion model to four health outcomes: low birthweight, infant mortality, chronic and acute illness, and perceived health status. The implications of this model for research and policy are discussed.     

Parental quality of life in the framework of paediatric chronic gastrointestinal disease

Chronic gastrointestinal diseases, such as inflammatory bowel disease (IBD) and celiac disease (CD), might have impact not only on the affected child but also on their parents since inside the family framework, a change in each member may have influence on the whole system. The aim of this study was to test the hypothesis that parents whose children have IBD or CD will have a lower quality of life (QoL) compared to parents of healthy children, as well as that lower QoL will be found among parents who perceive lower health related quality of life (HRQOL) of their child. 55 parents of children with IBD, 49 of CD and 53 parents of healthy children were included in the study. Children were aged 7-18 years. In order to measure parental QoL, a Croatian version of the WHOQOL-BREF questionnaire was administered, with four domains: physical health, psychological health, social relationship and environment. The Total QoL was calculated as a sum of all domain items. The parent-proxy report of children's HRQOL, PedsQL 4.0 Generic Core Scales was used. Main result shows that parents of children with IBD report a significantly lower psychological health, compared to parents of other children, and significantly lower physical health compared to parents of healthy children. Among parents of children with CD and parents of healthy children, better parental Total QoL was significantly correlated with better parental report of children's HRQOL, while for parents of children with IBD those associations were not found. Results of study show association between presence of the disease in offspring with poorer parental QoL, thus highlight the importance of supporting not only children with chronic disease but also involving their parents in psychosocial interventions, as well as supporting the patient's association groups which gather both children with chronic disease and their parents.     

Markers of Bone Metabolism Are Affected by Renal Function and Growth Hormone Therapy in Children with Chronic Kidney Disease

ObjectivesThe extent and relevance of altered bone metabolism for statural growth in children with chronic kidney disease is controversial. We analyzed the impact of renal dysfunction and recombinant growth hormone therapy on a panel of serum markers of bone metabolism in a large pediatric chronic kidney disease cohort.MethodsBone alkaline phosphatase (BAP), tartrate-resistant acid phosphatase 5b (TRAP5b), sclerostin and C-terminal FGF-23 (cFGF23) normalized for age and sex were analyzed in 556 children aged 6–18 years with an estimated glomerular filtration rate (eGFR) of 10–60 ml/min/1.73m². 41 children receiving recombinant growth hormone therapy were compared to an untreated matched control group.ResultsStandardized levels of BAP, TRAP5b and cFGF-23 were increased whereas sclerostin was reduced. BAP was correlated positively and cFGF-23 inversely with eGFR. Intact serum parathormone was an independent positive predictor of BAP and TRAP5b and negatively associated with sclerostin. BAP and TRAP5B were negatively affected by increased C-reactive protein levels. In children receiving recombinant growth hormone, BAP was higher and TRAP5b lower than in untreated controls. Sclerostin levels were in the normal range and higher than in untreated controls. Serum sclerostin and cFGF-23 independently predicted height standard deviation score, and BAP and TRAP5b the prospective change in height standard deviation score.ConclusionMarkers of bone metabolism indicate a high-bone turnover state in children with chronic kidney disease. Growth hormone induces an osteoanabolic pattern and normalizes osteocyte activity. The osteocyte markers cFGF23 and sclerostin are associated with standardized height, and the markers of bone turnover predict height velocity.     

The socioeconomic gradient in child health and noncognitive skills: Evidence from the Czech Republic

We investigate the presence of a socioeconomic status (SES) gradient in children’s health and noncognitive skill development, and its evolution with child age using cohort data from the Czech Republic. We show that family SES are positively associated with better child health. These effects start to emerge at age 3 and are persistent for all subsequent ages. We find a modest strengthening of the gradient as the children grow older. Similarly, at the lowest distribution of average family income, children lag in their noncognitive skills. We find evidence that children enter school with substantial differences in noncognitive skill endowments based on family SES. This correlation persists when controlling for poor health at birth, the roles of specific and chronic health problems, housing conditions, and partner characteristics. Maternal health status explains some of the association between family income and child noncognitive skills. We account for the endogeniety of SES and non-linearities in measures.     

Radioimmunoassay of bone morphogenetic protein in serum: a tissue-specific parameter of bone metabolism

Bone morphogenetic protein (BMP), a paracrine agent inducing cartilage and bone cell differentiation, circulates in the blood and is detectable by BMP radioimmunoassay. Serum BMP levels are higher in growing children and patients with Paget's disease than in normal adults. These observations are interpreted as evidence of a BMP function in the physiology of bone in health and disease.     

Non-carcinogenic risk assessment to human health due to intake of fluoride in the groundwater in rural areas of Gonabad and Bajestan,Iran: A case study

In this study, a field research regarding groundwater contamination with fluoride and its related health risks to human health was carried out in 39 rural areas of Gonabad and Bajestan, Iran, in 2017. The results indicated that fluoride levels in two rural areas exceeded the WHO guideline. A total of 55% and 4.7% of the studied rural areas in Gonabad and Bajestan, respectively, had fluoride levels below the minimum recommended value of WHO for fluoride (0.5 mg/L). In this article, chronic non-cancer risks to three different groups of people, adults, children, and infants, for exposure to the fluoride were assessed. Health risk index values for fluoride contamination for 44% and 90% of children and infants in rural areas of Gonabad and Bajestan, respectively, were more than unity (>1), which clearly reveals that these age groups at the studied areas are at the chronic health risk due to the intake of fluoride-containing water. The order of fluoride contribution to non-carcinogenic health risk among the studied age groups was infants > children > adults. Therefore, from a public health viewpoint, it would be prudent and important that risk reduction measures be implemented to diminish the total body burden of fluoride in residents.     

Various methods of using lincomycin for treating acute and chronic hematogenic osteomyelitis in children]

Comparative data on the treatment of 209 children with acute and chronic hematogenic osteomyelitis are presented; 128 patients hospitalized before 1974 were treated with antibiotics, mainly penicillin and streptomycin without sensitivity testing. From 1974 81 children were treated with lincomycin; 80 per cent of the isolates were sensitive to this antibiotic. In lincomycin therapy the method of electrophoresis on the disease focus, intrabone administration of the drug and administration of the drug into the bone cavity together with the blood clot during surgical interventions in cases with chronic hematogenic osteomyelitis were used. A marked decrease in the rate of the chronic forms of the disease was registered (from 77.2 to 8.8 per cent).     

唑尼沙胺单药治疗儿童癫痫疗效及骨代谢的影响

目的:探讨唑尼沙胺(Zonisamide ZNS)对儿童癫痫疗效及骨代谢的影响。方法:选择2013年3月至2014年3月到河北省儿童医院神经内科门诊及病房就诊的新诊断癫痫患儿,其中男性36名,女性24名,年龄在2-14岁,给予唑尼沙胺单药治疗,分别于服药前、服药后6月查血甲状旁腺素、血钙、磷、碱性磷酸酶和骨密度测定,并与对照组进行对比。对照组选择就诊于儿保科年龄、性别相匹配的正常儿童。并分析癫痫患儿发作频率及严重程度,评估疗效。结果:唑尼沙胺治疗53例癫痫患儿中,42例(79.2)无发作,8例(15%)有效,3例(5.7%)无效。且对骨代谢相关血清学指标、骨密度无明显影响。结论:ZNS对儿童癫痫有显著疗效,是一种广谱、耐受良好的抗癫痫药。     

Caretakers, child care practices, and growth failure in highland Ecuador

Problems for child health have been attributed to child and sibling caretaking. Nevertheless, our data from highland Ecuador suggest an ambiguous relationship between growth failure and the practice of peer care. In a region where levels of chronic undernutrition as measured by stunting exceed 75 percent and fully one-quarter of children under five are underweight, analysis of structured observations of a sample of 28 children reveals no statistical association between growth indices and the practice of older children caring for younger children. Qualitative data, however, indicate that the practice can be a complication in specific cases where children already suffer compromised health. While the advantages or disadvantages associated with particular caretakers appear secondary to the risks attending inadequate diets or the broader environment of rural poverty, the potential for difficulties to emerge from peer care suggests that community day care provides a valuable alternative in this context.     

免疫抑制剂治疗对儿童疫苗诱导的免疫保护性的影响及其相关机制

疫苗是目前公认的预防传染病的有效手段,接种疫苗可极大降低人群传染病的发病率和病死率。随着现代医学的进展,接受免疫抑制剂治疗肿瘤、器官移植、造血干细胞移植及慢性病的患儿生存率有了很大提高,但免疫抑制剂的使用会影响疫苗诱导的免疫保护效果及儿童时期疫苗接种的安全性,使这部分免疫低下的特殊儿童成为疫苗可预防疾病的高危易感人群。本文综述了免疫抑制剂对儿童疫苗免疫保护性的影响及其相关机制。     

Elevated asthma morbidity in Puerto Rican children: a review of possible risk and prognostic factors

Latino children represent a significant proportion of all US children, and asthma is the most common chronic illness affecting them. Previous research has revealed surprising differences in health among Latino children with asthma of varying countries of family origin. For instance, Puerto Rican children have a higher prevalence of asthma than Mexican American or Cuban American children. In addition, there are important differences in family structure and socioeconomic status among these Latino populations: Cuban Americans have higher levels of education and family income than Mexican-Americans and Puerto Ricans; mainland Puerto Rican children have the highest proportion of households led by a single mother. Our review of past research documents differences in asthma outcomes among Latino children and identifies the possible genetic, environmental, and health care factors associated with these differences. Based on this review, we propose research studies designed to differentiate between mutable and immutable risk and prognostic factors. We also propose that the sociocultural milieus of Latino subgroups of different ethnic and geographic origin are associated with varying patterns of risk factors that in turn lead to different morbidity patterns. Our analysis provides a blue-print for future research, policy development, and the evaluation of multifactorial interventions involving the collaboration of multiple social sectors, such as health care, public health, education, and public and private agencies.     

Vitamin D deficiency in children with cerebral palsy: A narrative review of epidemiology,contributing factors,clinical consequences and interventions

Sufficient vitamin D levels are necessary, not only for mineralization, normal growth and development of bones, but also for the prevention of fatal chronic diseases like diabetes mellitus, metabolic syndrome and cancer. This is of particular importance in children with neuro- and musculoskeletal disorders, especially cerebral palsy (CP). CP is a heterogeneous group of childhood developmental disability disorders described by uncharacteristic posture, balance, and movement. Patients with CP are at an increased risk of vitamin D deficiency and as a result reduced bone mineral density, bone fragility, osteopenia, and rickets. The present review aims to combine and summarize available evidence, regarding the epidemiology, underlying contributing factors, clinical consequences, and treatment interventions of vitamin D deficiency in children with CP.     

Habitual Snoring in school-aged children: environmental and biological predictors

Background

Habitual snoring, a prominent symptom of sleep-disordered breathing, is an important indicator for a number of health problems in children. Compared to adults, large epidemiological studies on childhood habitual snoring and associated predisposing factors are extremely scarce. The present study aimed to assess the prevalence and associated factors of habitual snoring among Chinese school-aged children.

Methods

A random sample of 20,152 children aged 5.08 to 11.99 years old participated in a cross-sectional survey, which was conducted in eight cities of China. Parent-administrated questionnaires were used to collect information on children''s snoring frequency and the possible correlates.

Results

The prevalence of habitual snoring was 12.0% (14.5% for boys vs. 9.5% for girls) in our sampled children. Following factors were associated with an increased risk for habitual snoring: lower family income (adjusted odds ratio [OR] = 1.46), lower father''s education (OR = 1.38 and 1.14 for middle school or under and high school of educational level, respectively), breastfeeding duration < 6 months (OR = 1.17), pregnancy maternal smoking (OR = 1.51), obesity (OR = 1.50), overweight (OR = 1.35), several respiratory problems associated with atopy and infection, such as chronic/allergic rhinitis (OR = 1.94), asthma (OR = 1.43), adenotonsillar hypertrophy (OR = 2.17), and chronic otitis media (OR = 1.31), and family history of habitual snoring (OR = 1.70).

Conclusion

The prevalence of habitual snoring in Chinese children was similar to that observed in other countries. The potential predisposing factors covered socioeconomic characteristics, environmental exposures, chronic health problems, and family susceptibility. Compared to socioeconomic status and family susceptibility, environmental exposures and chronic health problems had greater impact, indicating childhood habitual snoring could be partly prevented by health promotion and environmental intervention.     

Suppression of secondary hyperparathyroidism in children with chronic renal failure by high dose phosphate binders: calcium carbonate versus aluminium hydroxide.

Secondary hyperparathyroidism was suppressed over a period of one year in 12 children with chronic renal failure by using a regimen of mild dietary phosphate restriction and high dose phosphate binders. The patients were randomised to receive either aluminium hydroxide or calcium carbonate by mouth for six months and then crossed over to the other medication. Vitamin D (dihydrotachysterol) dosage was unchanged. Serum parathyroid hormone concentrations were reduced to within the normal range, urinary cyclic adenosine monophosphate values fell, plasma phosphate concentrations decreased, and the theoretical renal phosphate threshold increased significantly. Transiliac bone biopsy findings improved in four patients with adequate suppression of parathyroid hormone concentrations, deteriorated in two patients who were not compliant, and did not change in five patients in whom initial bone disease was mild. Growth velocity improved significantly. There was no difference in the clinical response, biochemical changes, or incidence of complications during treatment with the two agents. In view of the risk of aluminium toxicity the use of high dose calcium carbonate with dietary phosphate restriction and vitamin D supplementation is recommended in the control of secondary hyperparathyroidism in children with chronic renal failure.