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Pediatric Guidelines for DXA Scans, Treating Vitamin D Deficiency

An increasing number of children throughout the U.S. are at risk for osteomalacia and osteoporosis. Although many of these cases are due to inadequate levels of vitamin D, others may be at risk because of certain medical conditions or the chronic use of medications that affect bone density.

In response, Akron Children’s bone health team has developed guidelines for ordering and using DXA scans, along with guidelines for the evaluation, treatment and prevention of vitamin D deficiency in special pediatric populations.

“There wasn’t a lot of available information regarding DXA scans or the treatment of vitamin D deficiencies in pediatrics, so we saw an opportunity to increase awareness among pediatricians regarding high-risk patients,” said Kathryn Mosher, MD, physiatrist and head of the bone health team, which also includes specialists from endocrinology, neurology, rheumatology, radiology, genetics, nutrition, pulmonary medicine and pharmacology.

During her fellowship training at Virginia Commonwealth University Medical Center in Richmond, pediatric endocrinologist Mamatha Kambalapalli saw a need for a dedicated bone health team to provide optimal care.

After joining Akron Children’s in 2014, she became a member of our multidisciplinary bone health team.

“Juvenile osteoporosis is relatively uncommon, so it’s under-recognized,” Dr Kambalapalli said. “Children with conditions such as chronic inflammatory bowel disease, celiac disease, neuromuscular disorders, Turner syndrome, or a family history of osteoporosis are at increased risk for low bone density and osteoporosis.

“Healthy children with recurrent fractures without significant trauma need further evaluation, as this could be a sign of low bone density,” Dr. Kambalapalli said.

Treating low bone density
When low bone density is confirmed, the first steps are to optimize vitamin D and calcium intake. The team’s bone health guidelines provide information regarding screening and treatment of vitamin D deficiency. Medications should be reviewed to determine if there are any that impact bone health which could be reduced or eliminated. Children who are mobile should be encouraged to maintain a healthy lifestyle and engage in weight-bearing activity. Physical therapy may be involved to recommend weight-bearing exercises, when a child’s mobility is limited. A dietitian can also recommend foods that are rich in vitamin D and calcium, which can be incorporated into the diet along with supplements.

Pediatric-focused imaging
Our DXA scan room was designed to provide more space for patient families and to accommodate procedural sedation when needed. The radiology staff is specially trained to work with children and can modify techniques for those who are non-ambulatory.

“The preferred skeletal sites for DXA measurement in children are the lumbar spine and total body without the head, said Dr. Mosher. “These measurements may be difficult or impossible in non-ambulatory patients, or those with spinal hardware or contractures that make positioning difficult, so we use distal lateral femoral DXA for greater accuracy.”

In pediatrics, the hip is not the preferred imaging site due to variability in children’s skeletal development.

When low bone density is suspected, refer to these guidelines for the evaluation, treatment and prevention of vitamin D deficiency in special populations, and for ordering and utilizing DXA scans in the pediatric population.

If a concern is identified, make a referral to the Center for Diabetes and Endocrinology through Epic or call 330-543-3276.

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