Limited ambulation, poor nutrition predict fractures in children with neurologic condition

Stephen Padilla
11 Sep 2023
Limited ambulation, poor nutrition predict fractures in children with neurologic condition

Fragility fractures occur in a few children with long-term neurologic condition (LTNC) and are associated with limited ambulation, feeding difficulties, and poor nutritional status, according to a Singapore study.

Recommendations have been made to improve bone health in children with LTNC, which include promoting weight-bearing activities, looking out for underweight children, avoiding vitamin D deficiency, and ensuring adequate calcium intake.

“In addition to preventive measures and mitigating risk factors, using dual X-ray absorptiometry (DEXA) scan for assessment of bone mass in high-risk patients and treatment with bisphosphonates are the ways forward to optimize bone health in children with LTNC,” the researchers said. [Singap Med J 2023;64:550-556]

A retrospective review was conducted in patients with LTNC on follow-up in a paediatric neurology clinic and those who presented with fracture to a paediatric orthopaedic clinic to search for fragility fractures. The researchers then gathered data on patients’ demographics, medical history, intervention, biochemical bone markers, and fracture history.

Fragility rate

In total, 136 patients with LTNC were included, of whom 65 percent were dependent on mobility (Gross Motor Function Classification System [GMFCS] V), 60 percent were underweight, and 60 percent were fed via gastrostomy or nasogastric tube, or were on oral pureed diet. In addition, 60 percent of children were treated with anticonvulsants.

The local prevalence of fragility fractures was 3 percent. Such fractures were associated with low-impact activities such as transfer and dressing. Of the patients, 7.4 percent had undergone measurements of vitamin D levels and 33 percent of calcium levels.

The finding on fracture rate is similar to the 4 percent found in systematic review of five studies on children with cerebral palsy and 3.6 percent in schools for physically disabled children, including those with cerebral palsy, traumatic brain injury, encephalitis, myopathy, and chromosomal anomalies, in Japan. [Dev Med Child Neurol 2009;51:773-778; Environ Health Prev Med 2010;15:135-140]

“In our study, the risk factors for poor bone health included high GMFCS level, lack of regular weight-bearing exercises, being underweight, feeding difficulty, and use of anticonvulsant and steroid,” the researchers said. “The study also showed that only a minority of children had regular calcium and vitamin D monitoring and supplementation.”


Given the prevalent problem of poor bone health and the lack of guidelines on bone health monitoring in children with LTNC, the following recommendations were made by the researchers: promote weight-bearing activities, avoid vitamin D deficiency, and ensure adequate calcium intake.

However, excessive dietary calcium intake could exacerbate constipation and increase the risk of urolithiasis in nonambulant children with LTNC. [J Spinal Cord Med 2012;35:9-21]

“Therefore, we suggest that calcium replacement should be considered only if there is poor dietary intake of calcium,” the researchers said. “We also recommend bone health monitoring and management for children who are assumed to have osteoporosis if they have any history of fragility fracture or bone pain. [J Clin Densitom 2014;17:281-294]

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