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I read with interest this recent review article that summarises current knowledge about this subject. I have a number of comments that are pertinent to the discussion. As the authors allude to, there is currently a lack of good evidence on which we can base preventive management. Although calcium and vitamin D supplements are routinely used by some paediatric rheumatologists, there appears to be only one short term study suggesting this may be beneficial for bone density.1 The two studies quoted in relation to growth hormone therapy are methodologically flawed because neither have accounted for the change in apparent bone density, which will occur in any child who grows better for any reason when assessed by modalities such as dual energy x ray absorptiometry2,3
As illustrated by another article in the August 2002 edition of Archives,4 there is a lack of good evidence on which to base much paediatric management and it is imperative that further research, especially randomised controlled trials, is undertaken in the area of prophylaxis against osteoporosis in children with chronic disease on steroids. Paediatric endocrinologists will be familiar with the flurry of small uncontrolled studies undertaken in numerous groups of children with short stature when recombinant growth hormone became available. Many reports of short term improvements in growth velocity have not been supported by long term outcomes in height. There is a risk that a similiar phenomenon will occur with the use of bisphosphonates in children with chronic disease and low bone density without properly designed studies and satisfactory outcome measures.
The use of glucocorticoids in children with chronic disease occurs across many paediatric subspecialities and I would argue strongly that the management and prevention of osteoporosis requires specialist expertise just as the management of growth retardation currently does. It is important that in each tertiary centre such a specialist service is provided by one department that has expertise in the interpretation of bone density scans in children and the management of children with osteoporosis. Such individuals may not only be paediatric endocrinologists but may be a paediatric rheumatologist, a general paediatrician with a special interest in bone disease or a metabolic bone disease subspecialist. It is only in this way that we can learn more about the management of this condition and avoid children being treated inappropriately.