Diagnosed with juvenile arthritis at age 2, Kelly Rouba experienced the first signs of bone loss when she was nine. While trying to get up from a folding chair at a friend’s barbecue, “the chair tipped and fell forward and I broke both my femurs,” she recalls.
By high school Rouba had begun taking alendronate (Fosamax), a drug approved for the prevention and treatment of osteoporosis. Now age 34, she has bones of a woman at least twice her age. She has regular x-ray absorptiometry (DXA) scans to monitor her bone density and often uses a walker to help avoid falls, which could lead to more broken bones.
When Bone Loss Begins Early
While Rouba’s bone loss is more severe than most, her decline in bone health is far from unique. Research has shown that low bone mass, or osteopenia, is common among young adults with JA. Other research has shown that for many children, bone loss begins and fractures can occur early in the disease process, particularly in the spine.
In a 2010 Canadian study of 134 children who had begun corticosteroid treatment for rheumatic conditions in the previous 30 days, doctors found that nine of the children had already had at least one vertebral fracture. Six of the children had just one fracture, but three had two or three. All the children had lower than typical bone mass for their age.
Why Bones Go Bad?
Experts cite a number of reasons why children with JIA have weakened bones. The first is the disease process itself, say Laura Hillman, MD, professor of child health and professor of human nutrition at the University of Missouri, Columbia, and Washington University in St. Louis.
“Children should be growing and have a lot of formation,” she says. Yet the inflammatory process promotes the breakdown of old bone instead of the formation of new bone.
The other main reason is the use of corticosteroids. “Like inflammation, steroids interfere with bone formation and increase resorption [breakdown of bone],” says Dr. Hillman. “They also have some effects on calcium absorption and affect bone mineralization.”
Parents may not be fully aware of how much calcium and Vitamin D a child is getting in his or her diet. Both supplements play a vital role in helping to build strong bones, which are especially important for children with JIA. Joint pain also can make it more difficult for children with JIA to exercise or play outdoors in the sunshine. This causes them to miss out on an easy way to get Vitamin D.
Building Strong Bones: What You and Your Child’s Doctor Can Do
Fortunately there are things you and your child’s doctor can do to improve bone health. Here are seven to know:
- Keep the disease under control. Biologics drugs that are used for JIA has made this goal possible for increasing numbers of children. “There have been studies using TNF-inhibitors that have shown impressive improvement in underlying bone,” says Dr. Hillman.
- Minimize corticosteroids. When corticosteroids are needed, doctors should use the lowest dose that controls inflammation for the shortest amount of time possible. If just one or a few joints are inflamed, injecting corticosteroids directly into those joints reduces the bone-damaging risks of oral corticosteroids.
- Practice good nutrition. A diet rich in calcium can help reduce bone loss. “It’s probably worth investing in at least one trip to the dietitian to get a good dietary analysis to make sure your child is meeting their calcium requirement,” says Dr. Hillman. If you child’s not getting enough calcium, you should speak to her doctor about a supplement.
- Encourage exercise. Just like her muscles, your child’s bones are living tissue that needs exercise to get stronger. Weight-bearing and strengthening exercises are best for bones. Speak to your child’s doctor or a physical therapist about exercises that are safe for her joints. If pain keeps her from exercising, ask about pain relief options that can help her stay active.
- Get him outside. Your child’s body makes its own vitamin D in response to sunlight. If he spends too much time indoors playing video games, he could become vitamin D deficient. Dr. Hillman recommends a simple blood test to check vitamin D levels. If levels are low, speak to his doctor about a vitamin D supplement. Your child’s doctor may order periodic tests to monitor Vitamin D levels.
- Monitor bone density. Ask your child’s doctor about bone density tests. Many medical centers now have DXA machines for children. A DXA scan will tell your child’s doctor how her bone density compares to that of children her age. Repeating the scans periodically can show if bone density is changing and how well efforts to improve bone density are working.
- Build bones with medication. If a DXA scan reveals low bone density, your child’s doctor may prescribe a bisphosphonate medication, such as alendronate (Fosamax) to slow bone resorption and improve bone density. A review studies on the effectiveness of bisphosphonates treatment for children with JIA who had lower-than-expected bone density for children their age and sex showed an increase in spinal BMD from 4.5 percent to 19.1 percent.
Although JIA can have serious effects on bones, newer treatment approaches that allow better control of the disease, as well as the methods to detect and treat bone loss are making a difference. By working with your child’s doctor to provide the optimal treatment and promoting healthy lifestyle habits at home you can help protect your child’s bone health.