DXA Bone Scan — Clinical Recommendations by Body System/Clinical Disorder — Clinical Pathway: Inpatient, Outpatient Specialty Care and Primary Care

Bone Density Scan (DXA) Clinical Pathway — Outpatient Specialty Care and Primary Care

Recommendations by Body System

The tables below outline guidance for clinical recommendations by body system and clinical disorder.

Cardiovascular Disorders

Diagnosis Key Points DXA Recommendations
Fontan and Protein Losing Enteropathy Malnutrition from protein-losing enteropathy in the setting of cardiac disease increases the risk of low BMD
  • Indications for screening DXA unclear; consider in high-risk children:
    • Chronic glucocorticoid use
    • Chronic diuretic therapy
    • Clinically significant fractures

Endocrine Disorders

Diagnosis Key Points DXA Recommendations
Hypogonadism and Turner Syndrome
  • Children with gonadal hormone imbalance have increased risk of low BMD1
  • These children often receive estrogen (gonadotropin) replacement therapy and steroids, which increase the risk of low BMD
  • Screening DXA after initiation of adult hormones has been recommended
  • Follow-up frequency as indicated based on Z-score, other clinical risk factors

Gastrointestinal Disorders

Diagnosis Key Points DXA Recommendations
Celiac Disease
  • Celiac disease is a risk factor for low BMD secondary to malabsorption
  • Children with concomitant autoimmune endocrinopathy (type 1 diabetes, Addison’s disease, etc.) may be at higher risk of impaired bone health2
  • Strict adherence to a gluten-free diet typically results in resolution of low bone density
  • There is no strong evidence for routine DXA scans at baseline or follow-up
  • Consider DXA 1-2 yrs after diagnosis or when anti-TTG antibody normalizes.
Cystic Fibrosis
  • Children with cystic fibrosis are at increased risk of low BMD due to malnutrition, steroid use, and concurrent disease (cirrhosis, short bowel syndrome, celiac disease)3
  • Children without concurrent disease or malnutrition are at low risk for low BMD
Inflammatory Bowel Disease
  • Inflammation from IBD has an adverse effect on bone modeling and the muscle-bone unit
  • Chronic steroid use also increases the risk of low bone density
  • Low bone density often resolves with control of inflammation related to disease treatment4
  • Consider baseline at diagnosis
  • Repeat as needed with risk factors:
    • Persistent malnutrition
    • Short stature
    • Significant glucocorticoid therapy
    • Amenorrhea
    • Delayed puberty
    • Persistent inflammation
      • Increased CRP, ESR, or low albumin
    • Clinically significant fractures
    • Repeat every 1-2 yrs for height-adjusted Z-score < -1

Hematology and Oncology Disorders

Diagnosis Key Points DXA Recommendations
Chemotherapy for Childhood Cancer
  • Children treated with methotrexate and/or steroids are at increased risk for low BMD
  • Children who have undergone a hematopoietic cell transplant are at risk for low BMD5
  • Baseline DXA by 18 yrs old or 2 yrs after the end of chemotherapy
  • Screening DXA for high-risk children:
    • Severe disease
    • Low body weight
    • Chronic glucocorticoid therapy
    • Delayed puberty
    • Gonadal failure
    • History of fracture
Hematopoietic Cell Transplant (HSCT) Children who have undergone a hematopoietic cell transplant are at risk for low BMD9 Annual DXA screening and monitoring should be considered before and 12 mos after HSCT
Sickle Cell Anemia Sickle cell leads to a significantly reduced BMD compared with healthy subjects Screening DXA, follow up as clinically indicated
Thalassemia Children with thalassemia have lower BMD than healthy children and suboptimal peak bone mass Consider DXA and follow up as indicated based on Z-score

Neurologic/Neuromuscular/Neurodevelopmental Disorders

Diagnosis Key Points DXA Recommendations
Duchenne’s Muscular Dystrophy
  • DMD is associated with low BMD and increased fracture rates, especially in the setting of glucocorticoids6
  • Annual lateral spine radiograph for vertebral fracture recommended in all children on steroids
  • Annual DXA starting at age 5 yrs; frequency can be spaced to every 2-3 yrs in ambulatory males with Z-scores > 0
Ketogenic Diet Children on long-term ketogenic diet at risk for impaired bone accrual, as well as abnormalities in calcium metabolism7
  • Screening DXA in all children after 2 yrs on ketogenic diet
  • Follow-up frequency as indicated based on Z-score and other clinical risk factors
Neurodevelopmental Disorders (Autism, Rett Syndrome, etc) Children with autism and Rett syndrome at risk for low bone density d/t limited physical activity, restricted dietary intake8, 9
  • Indications for screening DXA in children with autism unclear; consider in children with fracture, limited activity or impaired dietary intake
  • Baseline DXA after age 5 recommended in all children with Rett syndrome
  • Follow-up frequency for both conditions as indicated based on Z-score, other clinical risk factors
Neuromuscular Weakness (Cerebral Palsy, Spinal Muscular Atrophy, Spinal Cord Injury, etc.) Children with neuromuscular disorders of any type have increased fracture rates and reduced DXA BMD Z-scores due to muscle weakness and immobilization10
  • Indications for screening DXA unclear; consider in high-risk children:
    • Fracture
    • Quadriplegia
    • Limited ambulation
    • Previous fracture
    • Anticonvulsant use
    • Low body weight/BMI
  • Follow-up frequency as indicated based on Z-score, other clinical risk factors

Renal Disorders

Diagnosis Key Points DXA Recommendations
Chronic Kidney Disease (CKD) Impaired bone health can occur due to CKD- metabolic bone disease (MBD). Low bone density may be additional factor in some children11
  • Indications for DXA screening in children are unclear
  • Current guidelines suggest screening DXA in children with CKD3a-G5d and in children post kidney transplant if a finding of low BMD will change clinical management

Other

Diagnosis Key Points DXA Recommendations
Eating Disorders
  • Defined as female adolescent with excessive exercise or
    > 6 mos of amenorrhea
  • Imbalance of the gonadal sex hormones increases the risk of low BMD
  • Indications for screening unclear; consider screening DXA in children with duration of illness 9-12 mos, fracture
  • Follow-up frequency as indicated based upon Z-score, other clinical factors
Gender Dysphoria/Transgender Health
  • The treatment of gender dysphoria in youth includes the use of gonadotropin releasing hormone analogs that may impair bone mineral accrual
  • Children with delayed onset or inconsistent sex steroid hormone administration may be at greater risk12
  • Indications for screening and monitoring with DXA are emerging
  • Current recommendations suggest monitoring DXA every
    1-2 yrs in children on puberty blockers
  • Z-scores should be reported respective to both assigned and affirmed gender
Steroid Exposure Chronic high dose steroid use decreases bone density and increases fracture risk
  • Consider screening DXA in children on chronic therapy for 90 days of hydrocortisone, prednisone/prednisolone, or dexamethasone at doses that exceed physiological replacement
  • Chronic Steroid Use
  • Follow-up frequency as indicated based upon Z-score, other clinical factors

Adapted from 2013 PEDS–ISCD Position Statement   and the 2016 AAP Guidelines for DXA Scans  

References

  1. Clinical Practice Guidelines for the Care of Girls and Women with Turner Syndrome: Proceedings from the 2016 Cincinnati International Turner Syndrome Meeting  
  2. Evidence-informed Expert Recommendations for the Management of Celiac Disease in Children  
  3. Guide to Bone Health and Disease in Cystic Fibrosis  
  4. Skeletal Health of Children and Adolescents with Inflammatory Bowel Disease  
  5. Guidance to Bone Morbidity in Children and Adolescents Undergoing Allogeneic Hematopoietic Stem Cell Transplantation  
  6. Diagnosis and Management of Duchenne Muscular Dystrophy, Part 2: Respiratory, Cardiac, Bone Health, and Orthopaedic Management  
  7. Optimal Clinical Management of Children Receiving Dietary Therapies for Epilepsy: Updated Recommendations of the International Ketogenic Diet Study Group  
  8. The Autism Treatment Network: Bringing Best Practices to All Children With Autism  
  9. Clinical Guidelines for Management of Bone Health in Rett Syndrome Based on Expert Consensus and Available Evidence  
  10. Informing Evidence-based Clinical Practice Guidelines for Children with Cerebral Palsy at Risk of Osteoporosis: an Update  
  11. Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease-Mineral and Bone Disorder: Synopsis of the Kidney Disease: Improving Global Outcomes 2017 Clinical Practice Guideline Update  
  12. Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline