Optimizing skeletal health during childhood will confer benefits for a patient's entire life, so it's never too soon for pediatric providers to discuss bone-building strategies with families, says sports medicine specialist Celina de Borja, MD. She offers reminders of the many organ systems impacted by the bones; describes risk factors for osteoporosis; notes red flags in kids; and discusses simple ways to modify lifestyle factors, such as using calcium and vitamin D supplements and prescribing reasonable exercise plans that won’t daunt sedentary teens.
Uh Good afternoon everyone. Uh I'm Selena De Boer. I'm a pediatric primary care, sports medicine specialist here at U CS F be Children's Hospital. So my background is in primary care, pediatrics, um followed by sports medicine uh training. Um Today, we will talk about optimizing bone health in the teens. Uh no relevant financial disclosures. So our main objectives for today include recognizing conditions that may interfere with adequate bone health and then also reviewing strategies to optimize bone health in Children and adolescents. So, before we begin with those objectives, um let's start with what is bone health. Uh According to the US. Surgeon general, bone health is a public health issue with an emphasis on prevention and early intervention to promote strong bones and prevent fractures and their consequences. Now, why do we have to talk about bone health? Why is it so important? Aren't bones just for movement or mobility? Well, the answer is no uh bones aren't just for movement or mobility. Bones actually have a lot of important roles um in the body. So first and foremost, bones protect our vital organs. Specifically, the brain protects our uh the skull protects our brain and the rib cage uh protects our heart and lucks. Uh bones are also involved in producing essential cells, specifically red blood cells, immune cells and is uh vital in a regulated electrolytes, specifically calcium. Now, when do we need to have this conversation about bone health? And the answer is as soon as you possibly can. Um Children have unique risk for fractures due to their skeletal immaturity and at the same time, their activity levels. Uh um but more importantly, 90% of peak bone mass is attained during childhood and adolescence. Um and this process of attaining a calcium into your bone bank actually slows down after 30 years old. And after 40 the bones actually lose more calcium than it builds uh thereby leading to osteoporosis. Now, where should we start? Now, cal this is the uh uh diagram on calcium homeostasis that shows that bones aren't the only organ systems that um are involved in uh calcium or bone health. Um There's other organ systems that are also involved, including our G I tract and our kidneys. Um And these organ systems uh are influenced by three hormones, mainly pth. So pth likes to keep uh calcium uh in the bloodstream, uh thereby um uh reabsorbing it from the bones, um and reabsorbing it from the kidneys as well as increasing um absorption from RG I tract. Now, this process is um also influenced by vitamin D. Vitamin D is the second uh hormone uh that is important in bone health because it helps with the absorption of uh of vitamin of calcium in our gut without adequate levels of vitamin D. We are all just um flushing out the calcium that we get from our dietary uh sources. And then lastly, calcitonin, calcitonin um likes to keep uh calcium in the bones. Uh And so and so it takes it from the bloodstream through reverse mechanisms. Now, who needs to have this conversation about bone health with the patients and their families. And the answer is all of us um most especially um you all um who are practicing in primary care, who know our patients best. I think it's really important to have these conversations with them. Um Us as musco skeletal orthopedic or resource medicine providers, we tend to um have these conversations um during specific issues and they also encourage any allies. Um for example, mental health specialists or nutritionists or physical therapists to have these conversations because certain risk factors or medical conditions might be more obvious in certain clinical settings, which brings me to my first objective, recognizing conditions that may interfere with adequate about health. So we start with intrinsic factors, age specifically during growth or adolescence and during elderly years um are common um risk factors for bone health um gender as well. We see uh impaired bone health issues in more in women compared to men. And you know, while we see impaired bone health issues in a wide variety of um ethnic backgrounds. We see it most commonly in white and Asian women, especially um when there's a family history of osteoporosis. Uh next would be medical factors. So, like I mentioned, primary care providers are the ones who know our patients best. So, um, please think about um issues with bone health. Um, if you're seeing them for these medical conditions, um first would be gastrointestinal or fat malabsorption. So for example, um those with inflammatory bowel disease, celiac or cystic fibrosis, you know, sometimes in Children or adolescents, these conditions may not necessarily be diagnosed right away. Um They may present with, you know, um a sensitive stomach, um you know, lactose intolerance or whatnot. And so in these conditions, I always think about their ability to absorb, you know, calcium and vitamin D uh individuals with chronic disease, specifically liver disease, kidney disease, um childhood cancers or inflammatory processes um may be at risk for impaired bone health. Um those uh with exposure to certain medications, for example, steroids, uh whether it is for chronic disease, uh inflammatory disease or say um respiratory exacerbations, you know, please think about their own health. Um Other medications um include anti convulsants, antifungals, antiretrovirals and antidepressants. And it has something to do with the cytochrome P 450 metabolism, uh that tends to interfere with um calcium homeostasis and then last but not the least um individuals um especially the adolescent athletes um with eating disorders. Um, so that could be more on the behavioral aspect. Um, it can, uh impair their bone health and we'll, um, discuss a little bit more. Um, in the next slide, uh for us who work in orthopedics or if you're ever seeing them in the setting of a musculoskeletal complaint, you know, think about impaired bone health. Um, when you see any of these conditions, um for Children, you know, two or more fractures um by 10 or more than three by adolescents. Um stress fractures um are injuries that make us think about um impaired V MD. Um vertebral compression fractures, especially if low um velocity or low mechanism. You know, we uh we consider that as a um as a red flag, you know, for B MD. Um and then for those um individuals where in there sustaining a pretty, you know, simple or straightforward fracture, but they're not healing um as expected within the 6 to 8 week time frame. Um or, you know, we may consider as delayed union. You know, we think about their uh metabolic um status um in those situations. And then outside of trauma, there are certain medical conditions um say, you know, cerebral palsy or neuromuscular conditions wherein Children are immobilized or not as active. Um when we think about impaired bone health. And then um some literature have suggested that other orthopedic associations, for example, skiffy or scoliosis uh may be related to impaired B MD. Um And so I if these cases, um especially if they're operative, we tend to do um some form of work up for them, uh modify bubble factors, um are really important when assessing bone health because these are things that um tend to have a pretty simple fix. So definitely look at their intake, dietary intake, um and look for sources um for calcium and vitamin D. So in Children and adolescents, you know, I asked specifically about restrictive diets um or an advocate nutrition. So sometimes it's um restrictions based on um you know, medical issues. Um sometimes it's from um social, cultural religious, um you know, uh preferences or sometimes you just have a child who's a very picky eater. And so, um you wanna make sure that they have adequate source of calcium and vitamin D. Um studies have shown that, you know, kids who have high protein, high sodium in their diet, they tend to um uh have reduced calcium retention. And so they're just flushing out calcium in their urine. And then studies also show that kids who consume a lot of soda and juices um are associated with lower intake of milk and calcium sources. And then lastly, uh obesity um because vitamin D is really important in calcium absorption and vitamins DD is a fat soluble vitamin, uh obese individuals tend to have their vitamin D six start into their fat cells. And so they have low vitamin D in their bloodstream and So this impairs their ability to absorb calcium from their diet. So think about that as well. Uh lifestyle habits um can also impact bone health, like we mentioned earlier, you know, kids with their muscular conditions or mobilized or inactive, um you know, can impact their bone health. So ask about the lifestyle of the Children. Um you know, and whether or not they have opportunities for high impact activities, um if they are not in organized sports, they typically ask about um opportunity for pe or running around in recess, uh or maybe recreational activities during the weekends that they may do with their families. Um because that can also um help with, you know, making strong bones um sleep, you know, has been documented to uh impact bone health. Um There is a study from the University of Buffalo from which this image is um obtain from, um they looked at 11,000 post menopausal women who have had dexa scans uh performed in their facilities. And what they found was that, you know, women who slept five hours or less um had lower bone mineral density compared to those who slept seven hours or more. And so the um explanation that the researcher suggested is that, you know, healthy processes such as bone remodeling or healing happens when we're sleeping. And so if we're sleeping less, these processes aren't happening adequately, which can impair our overall um bone mineral density. And then um last but not the least, you know, because my um area of interest and expertise is in sports medicine definitely would want to highlight any athlete or performing arts related factors that can interfere with adequate bone health. So um one phenomenon that was described in 1997 was a female athlete triad wherein a female athlete um would have an eating disorder uh would sustain a stress fracture. It would also have uh secondary amenorrhea or missed periods and that is reflected by the red triangle over here. Um Over time, the American culture sports medicine realized that um some of these individuals may not always be in the red triangle but can travel back and forth in between, you know, optimal energy availability um and optimal uh menstrual cycles. Um you know, depending on their level of, you know, sports engagement. Um In 2014, the concept of relative energy deficiency in sport was introduced um which showed that this triangle over here um is just a slice of a bigger pie uh with low energy availability as the um you know, main problem, low energy availability doesn't always mean that they have an eating disorder but that, you know, individuals um are not eating or getting as much nutrients uh that's uh adequate to keep up with the amount of exercise that um they perform. Um the important highlights with red S um are that, you know, the problems linked to low energy availability aren't limited to menstrual dysfunction or stress fractures. Um It also um can influence the immune function. It can also be associated with gastrointestinal issues and cardiovascular issues and other, um you know, physio physiologic functioning. Most importantly, um we realized that this phenomena aren't exclusive to women, but it can also happen to men as well. Um And that they're not just limited to physiological complications and that it can also impair an athlete or performers um performance abilities. And so now that we've um discussed um factors that may impair bone health. Let's review strategies that can help optimize them um in Children and adolescents and reviewing, you know, their overall state of health is really important. Um you know, having a good understanding of their dietary practices or any restrictions um that they may have, you know, discussing uh their lifestyle, uh specifically what types of physical activities they engage in, you know, for women asking about specific questions about their menstrual cycle. Um It's not enough that we ask them if they've had their periods or have long periods have um been going on. I think it's really important to ask um if they're having regular periods and although the literature may suggest, you know, it can be anywhere between, you know, 28 to 35 day cycle. I think it's also important to ask, you know, how many cycles they're having in a year. Um because studies have shown that girls who are having uh less nine or less than nine cycles each year, you know, may be at risk for um low energy availability. Um and you know, subsequently, you know, red s and impaired bone health and then fracture history. So, you know, a lot of times we meet them in the orthopedic clinic, um you know, for, you know, one injury or another. Um However, I think in primary care if you know the family well, and you know, have seen in their record that they've had, you know, two or more fractures um in, in the past, I think definitely something to um to consider. Um you know, family history is very important. Um We've learned uh through our, you know, rheumatologic and endocrine um colleagues that, you know, family history of impaired um bone health or osteoporosis, you know, can be, you know, a red flag for, you know, the child's future um uh you know, bone situation and then ultimately, the growth chart, you know, can give us clues about their overall um state of health. And so the American Academy of Pediatrics um doesn't necessarily recommend, you know, drawing labs on all kids, um you know, to evaluate them for bone health, they, you know, do encourage, you know, thorough history and, you know, physical exam, but they also encourage being proactive if there's any risk factors. Um a good place to start would be, you know, checking what um vitamin D levels and then that would be the 25 hydroxy vitamin D because that would be the, um, you know, best, uh, reflection of, of, you know, vitamin D storage. So this is a table, um, that, you know, guides us on how we're supposed to treat our supplement with vitamin D. And, you know, the ultimate goal is that the level is greater than 30. And that's because that's the number that seems to be protective of, uh, fractures in Children and adolescents. Um, And so if they have 30 to 50 then they're sufficient. They don't necessarily need any supplementation if they're getting it from their diet. Um, deficiency is defined as a level less than 20. Um because there's really high, you know, fracture risk, um or vitamin D deficiency. Um, you know, we recommend, you know, treating these with either the daily dose or the weekly bolus dosing and then rechecking in 6 to 8 weeks um to, to adjust their dose and then those in between, um those with levels 20 to 29 are considered insufficient. And so, um supplementation would be recommended for those um individuals. Um Again, um you know, although labs aren't nec necessarily indicated for everyone, um it doesn't encourage to be proactive if there is any risk factors. In addition to checking their vitamin D, sometimes other labs may be um recommended, you know, depending on the clinical picture, you know, a CBC uh would be helpful just to kind of, you know, see their overall state of health sometimes, you know, we can get uh a clue such as um anemia of chronic disease, you know, if there is any say underlying inflammatory logic or chronic um disease going on, um you know, electrolytes um are, you know, good um to kind of take a peek at their, you know, overall G I or renal um status uh inflammatory markers, if you're thinking of autoimmune condition, and then, um you know, parathyroid hormone could be checked. Um If you're thinking of an endocrine disorder, uh dexa scans um are imaging mortalities that um are used to evaluate individuals, bone mineral density. Although dexa scans aren't necessarily indicated for everyone. Um In fact, I do consult with our pediatric endocrinologist, you know, before requesting, you know, for these studies. Um but I just wanted to, you know, mention a few things about the pediatric Dexa scan so that um you know, it's not confused with, you know, the adult protocol. So the pediatric protocol um includes the spine and the total body less head. In contrast with the adult protocol, which looks at other areas such as femoral neck and um what not. Um The report for Children should include Z scores and not T scores which are used for adults. Um These scores are standard deviations that are based on sex, age and race ethnicity. Um match reference ranges and A Z score up to negative two should be fine, but anything that's lower than negative two is considered low bone density. Um The term osteoporosis is not necessarily used in uh the Dexa scan report in Children unless um there is clinically significant fracture history. So, um that would be that a score Z score of, you know, lower than negative two plus um either vertebral compression fracture from low energy trauma, you know, two or more fractures by 10 or three or more fractures by 19. So that's just something that was, has been shared with us by a pediatric endocrinology and, and radiology colleagues that would be helpful. And so, um you know, maintaining um healthy weight, you know, is important um in optimizing, you know, bone health. Um like we said earlier, if you, if weight is too low or energy availability is too low, then it can impair bone health. Um We also mentioned that obesity um you know, can be associated with uh sequestration of vitamin D and, you know, impairments in bone health. So, you know, just managing the weight is, is really important um for bone health. Um this uh image over here um is the athlete's plate. Um is something that I learned from our um mentors and um who are registered dietitians. It shows um essentially how individuals, especially athletes should adjust their diets, uh depending on their training. Um As you can see on the top, you know, if someone's having easy training or just, you know, working on weight management, then um there's more foods and vegetables, um, compared to the other, um, components of, of their plate. Um, however, when, you know, someone's undergoing hard training, then, you know, they need more carbs or grains. Um, you know, compared to the other components. Um, you know, bottom line is all macro nutrients are important. So, carbs, protein and fat, they're all important. Um, for, you know, a balanced diet, it's just a matter of, um, proportion that changes, depending on their exercise level. Um And then, like I mentioned earlier, you know, calcium and vitamin D um are, you know, actionable or, you know, areas where we, you know, can intervene. Um This is, this table is the RD A or recommended dietary allowance of calcium and vitamin D for Children and adolescents. And as you can see, as the child gets older, uh the numbers get bigger. Um what I wanted to highlight though was that, you know, our 9 to 18 year olds, um where, you know, is there, it's their kind of, you know, maximum, maximum kind of time, you know, for collecting calcium into their bone bank and they need 1300 mg a day. Um which, which is a lot. And so, you know, I definitely emphasize this with, with families to make sure that, you know, they're thinking of all um sources um from, from their diet, not just thinking, oh, you know, I drink milk and I'm good. And so um this uh slide, you know, shows um different sources of calcium, you know, in the diet, we are all aware of dairy um options. Um But don't forget, there's also non dairy options and calcium fortified foods that could be um obtained, you know, for, for the kids. And so, um just to, you know, going back to what I that, you know, 1300 mg um per day, you know, from 9 to 18. Um as you can see, you know, glass of milk is roughly 300 mg. And so it really would take, you know, almost four glasses of milk to make that RD A. And so, you know, making sure we're looking at other sources say yogurt seems to, you know, be more efficient, you know, delivering but 400 to 450 you know, preserving and then also considering other sources um that are non dairy, um same goes for vitamin D. Um while we only really need about 400 to 600 international units of vitamin D each day. Um As you can see, the so natural sources are typically from um fish like salmon, sardines, mackerel, tuna, um or um mushrooms. And, you know, these aren't necessarily um part of your children's diet. So making sure we're looking at, you know, fortified foods. Uh for example, you know, milk, orange juice, you know, or, you know, breakfast options to make sure that they're getting adequate um vitamin D in their diet. And then physical activity like, like we um talked about earlier, you know, physical activity, um high impact activities, you know, help with making strong bones. The American Academy of Pediatrics recommends 60 minutes of moderate to vigorous exercise each day. However, we all know that that's, you know, been challenging um for the kids for a lot of different reasons. We're also kind of living in different um society nowadays where, you know, we're in the digital world and, you know, um we're not moving as much anymore. Um studies show though that significant bone growth can be seen with just 20 minutes of exercise three times a week. So we try as much as possible to encourage them to engage in something um that will help increase their bone neural density. Um The type of exercise also matters. And so, um you know, we have athletes who are lower impacts, for example, they swimmers, cyclists. Um and, you know, although they are, you know, very active, they can have lower um bone marrow density compared to, you know, those who run and jump. So making sure they have some high impact exercises uh or plyometrics or resistance training in their regimen um is also recommended and then um on the other, you know, end of the spectrum, you know, we, you know, think about um overuse or overtraining. So, you know, making sure there's gradual increases in their load and you know, adequate rest in between um is really important in avoiding um overuse or stress fractures. And um that is it um for me today. Um Thank you uh once again um to our physician liaison for having me um talk today about bone health. Um And if you have any questions, we'll have a Q and A session afterwards. But I just wanted to share um as Maria has mentioned earlier, we are hosting again our pediatric and musculoskeletal and sports medicine conference. Um in March, it's gonna be March 22nd and 23rd. It's in person um at the MLK Research Center in Oakland, California. Um Day one is a pediatric musculoskeletal medicine for primary care. We'll talk about different topics like spine deformity, lower limb differences, fracture care. Um We also have pediatric endocrinology and pediatric radiology um to, to learn from for day one and then for day two, we have exciting topics from our pediatric sports medicine um colleagues um including physical therapists and athletic trainers. So, um really excited about this course and we're looking forward to um seeing you all there. Um The QR code on the right upper um corner um sends you directly to our registration page. But if you have any questions, please don't hesitate to reach out to myself or physician liaison for more information.
