Overview of pediatric bone problems and related osteoporosis

Osteoporosis is a well-established clinical problem in adults. Osteoporosis in pediatrics, on the other hand, is a new and evolving area, with certain unique diagnostic and clinical challenges. Recently, there has been an increased awareness of osteoporosis in children, both as a primary problem due to genetic mutations and enzyme deficiencies, and as secondary to various diseases, medications, and lifestyle issues. In this review we discuss the common forms of osteoporosis, including candidate genes, mutations of which can lead to primary osteoporosis, the mechanisms involved in the pathogenesis of secondary bone loss, and possible ways of diagnosing, preventing, or treating these conditions. The purpose of the article is to provide a summary of our current knowledge of pediatric bone problems and to provide a basis for discussion of the most appropriate ways to detect, treat, or prevent such problems.     

Overview: animal models of osteopenia and osteoporosis

Prior to initiating a clinical trial in a post-menopausal osteoporosis study, it is reasonable to recommence the evaluation of treatment in the 9-month-old ovariectomized female rat. A female rat of this age has reached peak bone mass and can be manipulated to simulate clinical findings of post-menopausal osteoporosis. Ample time exists for experimental protocols that either prevent estrogen depletion osteopenia or restore bone loss after estrogen depletion. More time can be saved by acceleration of the development of the osteopenia by combining ovariectomized (OVX) plus immobilization (IM) models. Methods like serum biochemistry, histomorphometry and densitometry used in humans are applicable in rats. Like most animal models of osteopenia, the rat develops no fragility fractures, but mechanical testing of rat bones substitutes as a predictor of bone fragility. Recent studies have shown that the prevailing activity in cancellous and cortical bone of the sampling sites in rats is remodeling. The problems of dealing with a growing skeleton, the site specificity of the OVX and IM models, the lack of trabecular and Haversian remodeling and the slow developing cortical bone loss have been and can be overcome by adding beginning and pre-treatment controls and muscle mass measurements in all experimental designs, selecting cancellous bone sampling sites that are remodeling, concentrating the analysis of cortical bone loss to the peri-medullary bone and combining OVX and IM in a model to accelerate the development of both cancellous and cortical bone osteopenia. Not to be forgotten is the distal tibia site, an adult bone site with growth plate closure at 3 months and low trabecular bone turnover and architecture similar to human spongiosa. This site would be most challenging to the action of bone anabolic agents. Data about estrogen-deplete mice are encouraging, but the ovariectomized rat model suggests that developing an ovariectomized mouse model as an alternative is not urgent. Nevertheless, the mouse model has a place in drug development and skeletal research. In dealing with drug development, it could be a useful model because it is a much smaller animal requiring fewer drugs for screening. In skeletal research mice are useful in revealing genetic markers for peak bone mass and gene manipulations that affect bone mass, structure and strength. When the exciting mouse glucocorticoid-induced bone loss model of Weinstein and Manolagas is confirmed by others, it could be a significant breakthrough for that area of research. Lastly, we find that the information generated from skeletal studies of nonhuman primates has been most disappointing and recommend that these expensive skeletal studies be curtailed unless it is required by a regulatory agency for safety studies.     

Understanding osteoporosis.

Considerable progress has been achieved recently in our understanding of the normal process by which bone mass is regulated. Age-related trabecular bone loss is characterized not simply by a global loss of bone but also by cortical porosity and loss of trabecular connections. Because bone strength depends on architectural as well as material properties, bone quantity alone cannot define fracture risk with precision. Traditional therapies for osteoporosis increase bone mass, and estrogen therapy, in particular, profoundly decreases fracture risk. The pharmacologic restoration of bone quantity and quality, however, remains elusive. Modern biotechnology offers the hope that progress may come about through the development of growth factors and other osteotropic compounds for clinical use.     

Studies on osteoporosis X. Effect of estrogen-progestin combination on heparin-induced osteoporosis

Neutron activation analysis was employed to determine total body calcium in C₃H/St(Ha) female mice. As 99% of body calcium is in bone, loss of calcium was used as an index of bone loss (osteoporosis). Heparin (500 U/kg b.i.d. caused bone loss in 3 months. Premarin (2 mg/kg q.d.) or norethindrone (40 mg/kg q.d.) alone prevented this osteoporosis. A Premarin-norethindrone combination (2 mg – 10 mg q.d. respectively) appeared to be somewhat more effective than either agent alone, but this difference was not significant at the 5% level. Combinations of estrogen and progestins may prevent metabolic bone disease at the same time reducing the danger of estrogen induced neoplasia.     

Hibernation and disuse osteoporosis.

In an attempt to determine 1) if disuse osteoporosis occurs naturally during hibernation and 2) if it can be induced by limb immobilization in active and hibernating ground squirrels, forty-six thirteenlined ground squirrels were divided into five experimental groups. Group one was the active control group (AC) (ten animals). Group two was the active immobilized (AI) group and was subjected to a unilateral sciatic nerve section (ten animals). Group three was the hibernating control group and was allowed to hibernate undisturbed for 30 days (HC) (ten animals). The fourth group was subjected to a unilateral sciatic nerve section and allowed to hibernate for 30 days; this was the hibernating immobilized group (HI). The fifth group of six animals received the identical treatment as the (HI) group but was allowed to hibernate for 150 days.The following measurements were taken: Gastrocnemius-soleus mass, body mass, tibia-fibula weight, total tibia-fibula calcium and phosphorus. In addition, the femur was observed histologically for the enlarged lacunae typical of osteoporotic bone. Statistical analysis was accomplished with the Wilcoxan sign rank test.The data were interpreted to mean: 1) Disuse osteoporosis can be induced in active ground squirrels, 2) disue osteoporosis is not evident nor can it be induced by limb immobilization during 30 days of hibernation and 3) limb immobilization did not result in significant disuse osteoporosis following 150 days of hibernation. Only a few enlarged lacunae were evident after 150 days of hibernation.