Linear growth and bone metabolism in pediatric patients with inflammatory bowel disease / Crescimento linear e metabolismo ósseo em pacientes pediátricos com doença inflamatória intestinal

Abstract Objective: To review the pathophysiology and evaluation methods of linear growth and bone mineral density in children and adolescents diagnosed with inflammatory bowel disease. Source of data: Narrative review carried out in the PubMed and Scopus databases through an active search of the terms: inflammatory bowel disease, growth, failure to thrive, bone health, bone mineral density, and children and adolescents, related to the last ten years, searching in the title, abstract, or keyword fields. Synthesis of findings: Inflammatory bowel diseases of childhood onset may present as part of the clinical picture of delayed linear growth in addition to low bone mineral density. The presence of a chronic inflammatory process with elevated serum levels of inflammatory cytokines negatively interferes with the growth rate and bone metabolism regulation, in addition to increasing energy expenditure, compromising nutrient absorption, and favoring intestinal protein losses. Another important factor is the chronic use of glucocorticoids, which decreases the secretion of growth hormone and the gonadotrophin pulses, causing pubertal and growth spurt delay. In addition to these effects, they inhibit the replication of osteoblastic lineage cells and stimulate osteoclastogenesis. Conclusion: Insufficient growth and low bone mineral density in pediatric patients with inflammatory bowel disease are complex problems that result from multiple factors including chronic inflammation, malnutrition, decreased physical activity, late puberty, genetic susceptibility, and immunosuppressive therapies, such as glucocorticoids.

Resumo Objetivo: Revisar a fisiopatologia e os métodos de avaliação do crescimento linear e densidade mineral óssea em crianças e adolescentes com diagnóstico de doença inflamatória intestinal. Fontes dos dados: Revisão narrativa a partir de pesquisa nas bases de dados PubMed e Scopus por meio de busca ativa dos termos inflammatory bowel disease, growth, failure to thrive, bone health, bone mineral density, children e adolescents nos últimos dez anos e com busca nos campos título, resumo ou palavra-chave. Resumo dos achados: As doenças inflamatórias intestinais com início na infância podem apresentar como parte do quadro clínico atraso do crescimento linear, além de baixa densidade mineral óssea. A presença de processo inflamatório crônico com elevados níveis séricos das citocinas inflamatórias interfere negativamente na velocidade do crescimento e na regulação do metabolismo ósseo, além de aumentar o gasto energético, comprometer a absorção de nutrientes e favorecer perdas proteicas intestinais. Outro fator importante é o uso crônico de glicocorticoides, que diminuem a secreção de hormônio do crescimento e dos pulsos das gonadotrofinas e ocasionam atraso puberal e no estirão do crescimento. Além desses efeitos, inibem a reprodução das células da linhagem osteoblástica e estimulam a osteoclastogênese. Conclusão: A insuficiência do crescimento e a baixa densidade mineral óssea em pacientes pediátricos com doença inflamatória intestinal são problemas complexos e que decorrem de múltiplos fatores, inclusive inflamação crônica, desnutrição, diminuição da atividade física, puberdade tardia, suscetibilidade genética a terapias imunossupressoras, como os glicocorticoides.

To assess the reduction in bone mineral density among children who completed steroid therapy for nephrotic syndrome

Introduction: Minimal Change Nephrotic Syndrome is the most common type of nephrotic syndrome accounting for 85% of cases. It is the most common primary or idiopathic type of nephrotic syndrome in children. It occurs between 1 to 12 years of age, but most commonly 2 to 6 years. Even though the majority of cases show remission of nephrotic syndrome, the hypocalcemia due to Glucocorticoids are very severe. It reduces the bone mineralization and reducing the bone mineral content and thereby reducing bone density. Aim of the study: To assess the reduction in bone mineral density among children who have completed the first course of steroid therapy for nephrotic syndrome by measuring biochemical markers of bone. Materials and methods: This study was done to find out the reduction in the Bone mineral density among children who completed steroid therapy for nephrotic syndrome, by using bone biochemical markers. This study also helped to assess the side- effect of Glucocorticoids on bone density and to prevent bone demineralization and pathological fractures in children. Results: The results showed there was a reduction in the serum calcium values among children with MCNS. This implied hypocalcemia among children due to GCs and the P value is significant <0.001. This represented the corrected calcium levels among the children after drug effect. It implied the D. Sampath Kumar, S. Prasanna, P. Sakthi Seethalakshmi. To assess the reduction in bone mineral density among children who completed steroid therapy for nephrotic syndrome. IAIM, 2018; 5(2): 94-104. Page 95 overall the corrected calcium levels at low levels with MEAN=8.34 mg%. The P value was <0.024 Significant. The total proteins were normal among children after completing the glucocorticoid therapy. The P value was <0.001 and was significant. Mean = 5.68. Standard Deviation (SD) = 0.28. The serum phosphorus was almost normal among remission MCNS Children and at higher levels among defaulters, SDNS and SRNS. Conclusion: Glucocorticoids is the drug of choice and standard therapy for Minimal Change Nephrotic Syndrome (MCNS), but the drug-induced hypocalcemia and hypovitaminosis D are assessed by our study. Added to the above, the disease itself characterized by hypocalcemia and hypovitaminosis D. So, all children should undergo this assessment to prevent growth failure and pathological fractures. Nutritional supplements are recommended for the quality of life among children.

Pediatric dual-energy X-ray absorptiometry: interpretation and clinical and research application / 소아과

Peak bone mass is established predominately during childhood and adolescence. It is an important determinant of future resistance to osteoporosis and fractures to gain bone mass during growth. The issue of low bone density in children and adolescents has recently attracted much attention and the use of pediatric dual-energy X-ray absorptiometry (DXA) is increasing. The process of interpretation of pediatric DXA results is different from that of adults because normal bone mineral density (BMD) of children varies by age, body size, pubertal stage, skeletal maturation, sex, and ethnicity. Thus, an appropriate normal BMD Z-score reference value with Z-score should be used to detect and manage low BMD. Z-scores below -2.0 are generally considered a low BMD to pediatrician even though diagnoses of osteoporosis in children and adolescents are usually only made in the presence of at least one fragility fracture.

Does Quantitative Tibial Ultrasound Predict Low Bone Mineral Density Defined by Dual Energy X-Ray Absorptiometry?

PURPOSE: Efforts for the early detection of bone loss and subsequent fracture risk by quantitative ultrasound (QUS), which is a non-invasive, radiation free, and cheaper method, seem rational to reduce the management costs. We aimed in this study to assess the probable correlation of speed of sound (SOS) values obtained by QUS with bone mineral density (BMD) as measured by the gold standard method, dual energy X-ray absorptiometry (DEXA), and to investigate the diagnostic value of QUS to define low BMD. MATERIALS AND METHODS: One hundred twenty-two postmenopausal women having prior standard DEXA measurements were included in the study. Spine and proximal femur (neck, trochanter and Ward's triangle) BMD were assessed in a standard protocol by DEXA. The middle point of the right tibia was chosen for SOS measurement by tibial QUS. RESULTS: The SOS values were observed to be significantly higher in the normal BMD (t score >-1) group at all measurement sites except for the lumbar region, when compared with the low BMD group (t score <-1). SOS was negatively correlated with age (r=-0.66) and month since menopause (r=-0.57). The sensitivity, specificity, and positive and negative predictive values for QUS t score to diagnose low BMD did not seem to be satisfactory at either of the measurement sites. CONCLUSION: Tibial SOS was correlated weakly with BMD values of femur and lumbar spine as measured by DEXA and its diagnostic value did not seem to be high for discriminating between normal and low BMD, at these sites.