Novel Care Boosts Pediatric Bone Health Outcomes

Endocrinology experts at Cincinnati Children’s are developing novel assessments and interventions that advance pediatric bone health in children with common, complex or rare medical conditions.

Efforts include:

• Advanced dual-energy absorptiometry (DXA) imaging interpretation
• Implementation of comprehensive inpatient and outpatient care for patients with skeletal fragility
• Research into the effectiveness of bisphosphonate therapy on fracture risk reduction

This work expands the Division of Endocrinology’s decades-long leadership in pediatric metabolic bone disease research and treatment.

“We have taken on several initiatives to improve the care of children with osteoporosis here in our community and as a referral center for children across the nation,” says Halley Wasserman, MD, MS.

Comprehensive Imaging, Interpretation and Clinical Services

The four physicians on our metabolic bone team are certified clinical densitometrists, with additional training in interpreting pediatric DXA scans. The team implemented clinician oversight for scan readings.

“This approach brings unique perspectives from clinicians who diagnose and treat metabolic bone diseases and other conditions affecting bone health to the clinical application of bone density measurement,” says Nat Nasomyont, MD, MS.

To provide better care, Wasserman and Nasomyont established a metabolic bone team to address concerns for skeletal fragility in chronically hospitalized patients.

“Waiting for them to come to us in the outpatient clinic wasn’t the ideal treatment situation, so we started to come to them,” Wasserman says.

Nasomyont and Wasserman now provide bone consultative services for hospitalized patients with fragility fractures or poor bone mineralization. The team aims to complete an evaluation within 48 hours of the request.

“We’re often consulted on patients treated here for rare diseases where skeletal fragility is a comorbidity, so our team’s comprehensive approach to understanding and evaluating bone health is fundamental,” Wasserman says.

Collaborative Research

Cincinnati Children’s is part of a national consortium studying the impacts of bisphosphonate therapy on fracture risk reduction in children. Participating institutions are building a registry of pediatric patients receiving bisphosphonate infusions. This collaboration will provide the data for multiple studies to evaluate different treatment approaches for skeletal fragility in rare diseases, enhancing clinicians’ ability to make evidence-based decisions, personalize treatments and improve patient outcomes.

“Our long-term goals are to improve bone density, reduce risk of fractures and identify conditions where unique pharmacologic interventions are required,” Wasserman says.

The bone health team also is exploring different imaging techniques, like trabecular bone score and MRI spectroscopy in children and adolescents. Researchers are looking for ways to better characterize skeletal health.

Studying Bone Health in Specific Patient Populations

Our bone health team also researches methods for assessing and treating bone health issues and identifying fracture risk caused by a primary condition or its treatment. We focus on conditions that may compromise peak bone accrual during adolescence, such as:

• Bone marrow transplant
• Duchenne’s muscular dystrophy
• Spinal muscular atrophy
• Turner syndrome

We take part in disease monitoring programs for rare bone diseases such as X-linked hypophosphatemia and autosomal dominant hypoparathyroidism.

Our recent research is getting noticed. Two articles were published in March 2025:

• Effect of Transdermal Estrogen Therapy on Bone and Neurobehavioral Health in Youth with Premature Ovarian Insufficiency: A Case-Control Study appears in the Journal of Pediatric and Adolescent Gynecology. We assessed the impact of transdermal estrogen replacement therapy (TDE2) in adolescents with premature ovarian insufficiency (POI). Results showed an increase in central bone mineral density (BMD) in adolescents with idiopathic POI in response to TDE2. Peripheral BMD measures were unchanged nor were there significant changes in volumetric measures of bone. The impact on neurocognitive outcomes in these adolescents remains uncertain.
• Bone Mineral Density Changes in Patients on Drug Therapy for Spinal Muscular Atrophy appears in the journal Neuromuscular Disorders. Patients with spinal muscular atrophy (SMA) are at higher risk of reduced bone health from decreased ambulation and mobility. While SMA-disease modifying therapy is improving the muscle health of these patients, it did not lead to normalization of bone mineral density measured by dual energy X-ray absorptiometry (DXA). Patients on treatment had fewer fractures compared to pretreatment. SMA drug therapy may decrease fractures in patients with low BMD, but more research about the long-term effects is needed.

Our earlier work includes studies of:

• Long-term bone health outcomes after adolescent bariatric surgery. Our research shows that a decade after patients received adolescent bariatric surgery, bone mineral density was lower than that of non-surgical peers of similar age and body mass index (BMI). The greatest difference was found at the hip.
• Bone mineral density and dickkopf-1 in teens with non-deletional hemoglobin H disease. We showed a high prevalence of low BMD in adolescents with non-deletional hemoglobin H disease. Our work also showed the protein dickkopf-1 is inversely associated with total body BMD, suggesting it may serve as a bone biomarker in this patient population.

More research is needed to understand the impact of fracture risk for these patient populations, Nasomyont and Wasserman say. Future work will focus on ways to identify and reduce fracture risk for specific conditions and improved imaging techniques to assess skeletal health.

(Published April 2025)

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