儿童骨质疏松的诊疗进展

Progress on the diagnosis and treatment of osteoporosis in children

骨质疏松症属代谢性骨病范畴,常见于老年人,儿童骨质疏松相对少见但更值得关注。在病因学上同样分为原发性和继发性,原发性主要见于潜在遗传性疾病的儿童,而继发性主要起因于慢性病及其相关治疗。既往骨折史以及后背痛常提示骨质疏松的存在,而在影像学上骨皮质变薄或低骨密度同样预示着骨折的风险。儿童骨质疏松的诊断工具优选双能X线骨密度仪,对于那些处于继发性骨质疏松风险的儿童,要保持高度警惕,而对于那些已经罹患骨质疏松的儿童,应尽量避免或减少可能进一步损伤骨骼的因素,以及尽早给予充足的钙及维生素D。治疗重点应侧重于改善功能结局,同时也应认识到生长发育期本身椎体重塑或症状自发缓解的可能性,因此应尽量避免不必要的治疗。双膦酸盐目前为治疗首选,但在儿童骨质疏松中证据有限,长期应用的时间及剂量仍有争议。尽管目前抗骨吸收的药物有很多种,但仍缺乏促进骨形成药物的研究,希望未来有更多适合儿童骨质疏松治疗的证据来填补这个空缺。

Osteoporosis is a metabolic bone disease particularly common in the elderly. Osteoporosis in children is relatively rare,but is of great concern. Osteoporosis in children can be etiologically primary or secondary due to chronic disease. Primary osteoporosis mainly result from underlying genetic disease,whereas secondary osteoporosis is caused by chronic diseases and the associated treatment. Previous fractures and backaches are clinical predictors,and low cortical thickness and low bone density are radiological predictors of fractures. Dual energy X-ray absorptiometry（ DXA） is the first choice for osteoporosis diagnosis in children. We should pay more attention to children who are at risk for secondary osteoporosis,and in affected children,further weakening of the bones should be avoided through minimizing exposure to osteotoxic medication and optimizing nutrition including calcium and vitamin D. Treatment should focus on improving functional outcomes. It is important to identify patient groups in whom spontaneous vertebral reshaping and resolution of symptoms occur during growth to avoid unnecessary treatment. Bisphosphonate therapy remains the first choice of pharmacological treatment of osteoporosis in children,despite there are limited evidence for its usefulness in the pediatric population. The duration and dose of treatment remain a concern for long-term safety. Various new potent antiresorptive agents are being studied,but more urgently required are studies using anabolic medications that stimulate bone formation.