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One-third of children will sustain a fracture by the age of 17 years, and 25–35% of these will be of the distal forearm. There is evidence that childhood fractures are linked to underlying skeletal fragility.1 Low bone mineral density (BMD), measured by dual-energy X-ray absorptiometry (DXA), has been shown to be associated with increased fracture frequency in children;2 other factors, including vigorous activity, are associated with changes in bone microarchitecture.2–4 Early identification and treatment of children who are at increased risk of fracture may lead to the optimisation of bone health in later life.4
Current challenges to investigating bone fragility in children
There are limited technologies used to investigate childhood bone health. Bone biopsy is limited due to its invasiveness, pain and general anaesthetic requirements. Most commonly, BMD is measured by DXA. A low BMD in children is defined as a Z-score of ≤ −2.0.5 The site-specific Z-score uses a reference population of children who are age, sex and ethnicity matched. T-scores (adults) are not appropriate for children as they use the average peak BMD attained in early adulthood.
The clinical relevance of a low BMD in childhood is not fully understood.2 However, it is accepted that children with a low BMD are at an increased risk of developing osteoporosis. The International Society of Clinical Densitometry in 2014 stated that in children “…the diagnosis of osteoporosis requires the presence of both a clinically significant fracture history and low BMD”.6 A significant fracture history is …
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