SAN FRANCISCO — Glucocorticoids and retinoids are important treatment mainstays for a variety of dermatologic conditions in children, but their adverse effects on bone health should make clinicians think twice before prescribing them, Dr. Laura K. Bachrach said at a meeting of the Society for Pediatric Dermatology.
“It's astounding how often this isn't done,” said Dr. Bachrach of Stanford (Calif.) University. “Specialists tend to have tunnel vision on their organ of interest. If you're a cystic fibrosis doctor, you watch the lungs and you don't think about vitamin D. If you're a rheumatologist, you may hone in on renal function and forget about other factors.”
The first thing to do when a child is prescribed steroids or retinoids is to optimize the child's nutrition. Make sure they're receiving adequate calories, protein, calcium, and vitamin D. In terms of vitamin D, children should have an annual measurement of their 25-hydroxyvitamin D concentration. The current consensus is that an adequate concentration is at least 20 ng/mL.
A multivitamin supplement is simply inadequate for children who have low vitamin D concentrations, Dr. Bachrach said.
Megadoses of oral ergocalciferol (10,000 U/wk for children under the age of 6 and 50,000 U/wk for older children) for 6–8 weeks are usually necessary to restore a child's vitamin D levels.
Prescribing physical activity is also important. This activity should be titrated to the patient. It's especially important to navigate between the twin hazards of immobilization and overuse.
Even children who need wheelchairs should be encouraged to at least stand. At the same time, you don't want children to exercise so much that they greatly increase their risk of fracture. Overexercise can also lead to slow weight gain.
It's also important to address any underlying endocrine disorders in these children. Deficits in sex steroids should be addressed, and in cases of delayed puberty, an endocrinology consult may be in order.
Most drugs for adult osteoporosis are contraindicated or have been inadequately tested in children, Dr. Bachrach said.
Parathyroid hormone can't be used in children because of the risk of osteosarcoma. And while bisphosphonates have been shown to be highly effective in adults, most studies in children have been observational, except in the case of osteogenesis imperfecta. There have been no studies in children with chronic disease and no consensus on duration or dose.
Furthermore, bisphosphonates have both minor and major adverse effects. They can cause fever, myalgia, bone pain, and GI pain or distension. More rarely, they can cause esophageal or oral erosion, delayed bone healing, or osteopetrosis, and there's also a risk of teratogenicity.
Bisphosphonates should be restricted to cases of osteogenesis imperfecta, children with fragility fractures, and randomized, controlled trials. They should not be used for low bone density only, and they definitely shouldn't be used as prophylaxis in children who are getting steroid therapy, she concluded.