Aim Children treated for malignancies are at increased risk of fractures due to a number of factors; prolonged steroid use, periods of immobility, malnutrition, chemotherapy induced Fanconi’s syndrome, and radiotherapy. Furthermore, the role of vitamin D is becoming more apparent and its deficiency may also lead to fractures.
We chose to evaluate the need to measure vitamin D levels in children with malignant disease to identify those patients who may need supplementation that could potentially prevent fractures occurring.
Methods 64 children were diagnosed with a malignancy and treated at our local centre between January 2010 and November 2013. A retrospective analysis was undertaken of electronic and paper case note records for those children who developed a fracture.
Results There were 6 children with fractures who aged between 2 and 12 years. 5 children were Caucasian and one child Asian. 5 were female and 1 male.
5 children had a diagnosis of ALL treated on UK ALL 2003 (2 regime A, 1 regime B, 2 regime C). 1 child had Ewing’s sarcoma and was treated on EuroEwing’s 99. None received radiotherapy.
Fracture sites were; 1 distal ulna, 4 foot/ankle, and 1 tibia. 1 fracture was associated with falling off bike, the others with minimal or no trauma.
All fractures occurred after the initiation of treatment, ranging from 5 months to 25 months in those with ALL. In the child with the Ewing’s sarcoma, the fracture occurred 2 months after completion of treatment presumed secondary to severe Fanconi’s syndrome from Ifosphamide.
Body mass indexes (BMI) at the time of fracture were; 1 on 0.4th centile, 3 on 50th centile, 1 on 75th centile, and 1 above the 99.6th centile. DEXA scan Z score of lumbar spine available for 3 children; –3.9, 0.8, and 1.0.
Vitamin D deficiency (defined as <50 ng/ml) was identified after fracture in 4/5 patients (one child not tested), with mean Vitamin D levels being 40.5 ng/ml. Of note 4/5 fractures occurred in summer months. Vitamin D deficiency was subsequently treated with supplementation.
Conclusion Children with malignant disease are at high risk of fractures. The evaluation and treatment of vitamin D deficiency may prevent a treatable cause for these fractures.