Osteoporosis, characterized by low bone density, is a common diagnosis among post-menopausal women. Juvenile osteoporosis refers to the same condition in children. People with osteoporosis have an increased risk for bone fractures, which can be avoided or reversed with proper medical intervention.

The Importance of Vitamin D and Calcium

Juvenile osteoporosis is often caused by an underlying condition that adversely affects calcium or vitamin D regulation in the body, such as gastrointestinal malabsorption or kidney disease. Medical treatment includes addressing the underlying disease, while dietary treatment focuses on ensuring that the child has adequate vitamin D and calcium intake. Vitamin D is important because it promotes dietary calcium absorption and plays a regulatory role in bone mineralization.

The child may absorb less than normal amounts of either vitamin or mineral, due to the underlying condition. In some cases, the child is on medication that adversely affects bone density, such as anti-seizure medication or steroids. Some patients do not have an underlying condition, in which case their osteoporosis is classified as idiopathic.

To diagnose juvenile osteoporosis, doctors may order blood and urine tests in addition to requesting a DEXA scan, which measures the child’s bone density. Doctors may prescribe oral supplementation if a deficiency exists and refer the child to be evaluated by a registered dietitian whose responsibility is to make the necessary dietary interventions to maximize the child’s calcium and vitamin D intake, while promoting normal growth and development. Serum calcium and vitamin D levels may be monitored every three to six months until the levels are normalized. DEXA scans may be done annually.

Eating the Right Diet

The American Academy of Pediatrics recommends children under the age of 18 years consume 400IU of vitamin D each day, and 500-1300mg of calcium depending upon age. The best natural food source of vitamin D is the skin of wild fatty fish, such as tuna, mackerel or salmon. Egg yolks and cod liver oil contain smaller amounts of vitamin D.

A dietitian may suggest that a child over the age of one year with juvenile osteoporosis eat wild fatty fish, egg yolks or cod liver oil, in various amounts, depending upon the child’s vitamin D status and current intake. The dietitian may also recommend that the child eat foods that are naturally high in calcium, such as cheese, cow’s milk, and yogurt on a consistent basis. Parents may find that the child will accept these foods as condiments, add-ons, and toppings onto foods with which the child is already familiar, such as adding extra cheese and milk to macaroni, serving yogurt dip with fruit for dessert and preparing oatmeal with milk instead of water.

“Picky eaters” who dislike the taste of these foods and children who lead vegetarian lifestyles may benefit from including non-animal foods that are fortified with vitamin D and calcium, such as orange juice, soy milk, bread, and cereal into their diet. The calcium and vitamin D content of commonly consumed food is available on National Institute of Health and United States Department of Agriculture Web sites.

Challenges for Dietitians

Fortifying the diet with adequate vitamin D and calcium to significantly improve deficiencies poses a challenge to the dietitian who treats a child with juvenile osteoporosis. For example, one cup of soy milk is equivalent to 100IU of vitamin D. Some children require 1000IU of vitamin D supplementation each day. A child would have to consume 10 cups of soy milk each day to meet this requirement.

When dietary intervention is not enough, oral supplementation is prescribed. Common forms of calcium supplements include calcium carbonate (i.e. Tums®) and calcium citrate. Calcium carbonate should be taken after a meal, while calcium citrate is readily absorbed regardless of mealtime. Young patients may prefer chewable calcium supplements to solid pills. Ergocalciferol (vitamin D₂) is a prescription vitamin D supplement available only in liquid form. The dietitian providing therapy to the child with juvenile osteoporosis must consider the child’s meal times before making oral supplement, as well as dietary recommendations.

Equally important to the child’s intake of calcium and vitamin D is the amount of time the child is exposed to sunlight and engages in weight-bearing physical activity. Sunlight activates the form of vitamin D that is naturally present in skin. Every clothed child should be exposed to approximately two hours of sunlight per week in order to synthesize adequate vitamin D. Also, engaging in regular weight bearing physical activities promotes the maintenance of bone mass. The American Heart Association recommends that children receive a minimum of 60 minutes of moderate-to-vigorous exercise each day. Good examples of weight-bearing activities include stair climbing, brisk walking, running, hiking, and dancing. Parents should be educated on the positive effect that exposure to sunlight and weight-bearing activities have on their child’s bone health and encouraged to make lifestyle changes that support them.

Diet therapy provided to the child with juvenile osteoporosis must be maintained so long as the child has a calcium and vitamin D deficiency or the child’s bone mass density remains low. Caffeine, salt, and high protein intakes inhibit calcium absorption and should be avoided. With appropriate care including mindful eating habits, a child with juvenile osteoporosis can expect an improvement in their condition.

— Katherine Boyce, MS, RD, LD, is a Sodexo dietitian and manager of the outpatient nutrition department, counseling pediatric patients at the Medical University of South Carolina Hospital in Charleston, S.C. Questions and comments can be directed to editorial@therapytimes.com.