The assessment and management of bone health in pediatric-onset rheumatological diseases from early age to adulthood: A critical overview

Despite the advancements achieved in modern rheumatology, patients with pediatric-onset rheumatological diseases are still exposed to systemic and/or articular inflammation and corticosteroid treatment, all exerting detrimental effects on the growing skeleton together with the reduced body weight and scarce physical activity that rheumatological patients usually experience. The assessment of bone mass in pediatric subjects carries computational limitations: Dual energy X-ray Absiorptiometry (DXA) underestimates bone mineral density (BMD) especially in case of smaller bone, an instance that occurs frequently in children with rheumatologic conditions due to the high rate of short stature or pubertal delay. The rates of low BMD in juvenile idiopathic arthritis (JIA) patients range between 3 % and 34 %, being higher in systemic and polyarticular JIA; patients with juvenile onset systemic lupus erythematosus (jSLE) present a low BMD in approximately 1/3 of cases. Such reduction in BMD presents early on disease course, persists with aging but might be reversed by rheumatological treatment. In pediatric populations, the term osteoporosis should be reserved to children with clinically relevant fractures, favoring “low BMD for chronological age”. The prevalence of vertebral fractures ranges between 10 % and 30 % in JIA, peaking in female JIA patients aged 10–15 years, and between 21.4 % and 52 % in jSLE. While calcium and vitamin D supplementation should be optimized in all pediatric patients with rheumatological conditions, bisphosphonates should be reserved to subjects with fragility fractures; the prescription for primary fracture prevention in glucocorticoid-treated children is recommended only in case of a dosage <0.1 mg/kg/day for at least 3 months.