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Meder M, Jelley H, Kocolas I, Al-Hamad D. Hypotonia and Poor Weight Gain in a 4-month-old Girl. Pediatr Rev 2024; 45:354-357. [PMID: 38821897 DOI: 10.1542/pir.2021-005379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 10/28/2022] [Accepted: 11/08/2022] [Indexed: 06/02/2024]
Affiliation(s)
- Michelle Meder
- University of Utah, Salt Lake City, UT
- Primary Children's Hospital, Salt Lake City, UT
| | - Hannah Jelley
- University of Utah, Salt Lake City, UT
- Primary Children's Hospital, Salt Lake City, UT
| | - Irene Kocolas
- University of Utah, Salt Lake City, UT
- Primary Children's Hospital, Salt Lake City, UT
| | - Dania Al-Hamad
- University of Utah, Salt Lake City, UT
- Primary Children's Hospital, Salt Lake City, UT
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2
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Dattagupta A, Petak S. A Case of Hypophosphatasia With Normal Alkaline Phosphatase Levels. AACE Clin Case Rep 2024; 10:38-40. [PMID: 38523854 PMCID: PMC10958627 DOI: 10.1016/j.aace.2023.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 10/17/2023] [Accepted: 11/17/2023] [Indexed: 03/26/2024] Open
Abstract
Background/Objective Hypophosphatasia (HPP) is a rare disease associated with low serum alkaline phosphatase (ALP) activity. Here, we present a case of a patient with normal serum ALP levels diagnosed with HPP. Case Report A 36-year-old woman presented with progressive fatigue, weakness, and joint pain. She had been evaluated in the past for genetic disorders due to these symptoms and was found to have a history of several total ALP levels within normal limits but elevated vitamin B6 levels. She also reported having loose teeth and "gray gums" during her childhood. Bone-specific ALP was tested for suspicion of HPP and returned at 4.4 μ/L (reference range, 5.3-19.5 μg/L), which prompted genetic testing. Genetic testing confirmed a positive pathogenetic variant of the ALPL gene, the c.542C>T (p.Ser181Leu) variant. She started asfotase alfa treatment to improve her symptoms. Discussion HPP was diagnosed based on clinical suspicion supported by laboratory findings, which can cause it to be underdiagnosed or misdiagnosed. Current literature reports that a low total ALP level is the main biochemical marker of HPP and the only level needed to diagnose the disease. However, bone-specific ALP, a common marker used for bone turnover, has not been required to be tested. Conclusion This case highlights a patient with normal total ALP, but low bone-specific ALP diagnosed with HPP confirmed by genetic testing. This case warrants future investigation into the diagnostic approach to HPP and the diagnostic utility between ALP and bone-specific ALP.
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Affiliation(s)
- Antara Dattagupta
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Houston Methodist Hospital, Houston, Texas
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Steven Petak
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Houston Methodist Hospital, Houston, Texas
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Baroncelli GI, Carlucci G, Freri E, Giuca MR, Guarnieri V, Navarra G, Toschi B, Mora S. The diagnosis of hypophosphatasia in children as a multidisciplinary effort: an expert opinion. J Endocrinol Invest 2024; 47:739-747. [PMID: 37752373 PMCID: PMC10904512 DOI: 10.1007/s40618-023-02199-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 09/12/2023] [Indexed: 09/28/2023]
Abstract
Hypophosphatasia (HPP) is a rare genetic disorder in which pathogenic variants of the ALPL gene lead to a marked decrease of tissue non-specific alkaline phosphatase (TNSALP) activity. Although HPP is a systemic disorder, its clinical manifestations are more evident on bones, teeth, muscle and central nervous system. The clinical spectrum ranges from severe forms with extreme skeletal deformities, respiratory impairment, seizures, to very mild forms with onset in late adulthood and few clinical signs. The diagnosis can be suspected by measurement of TNSALP activity, but the insufficient awareness among health professionals and the lack of official guidelines are responsible for delayed diagnosis in children with HPP. The purpose of the current document is to provide an expert opinion directed at optimizing the diagnostic pathway of pediatric HPP. From April to December 2022, a multidisciplinary working group of 6 experts including two pediatric endocrinologists, a pediatric neurologist, a pediatric odontologist, a clinical geneticist, and a molecular biologist gathered in a series of periodic meetings to discuss the main issues related to the diagnosis of HPP in children and formalize an Expert Opinion statement. The experts agreed on a diagnostic trail that begins with the recognition of specific clinical signs, leading to biochemical analyses of TNSALP activity and vitamin B6 serum concentration. Very important are the neurological and dental manifestation of the disease that should be thoroughly investigated. The evaluation of TNSALP activity must consider sex and age variability and low activity must be persistent. Repeated blood measurements are thus necessary. The molecular analysis is then mandatory to confirm the diagnosis and for genetic counseling.
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Affiliation(s)
- G I Baroncelli
- Pediatric and Adolescent Endocrinology, Division of Pediatrics, Department of Obstetrics, Gynecology and Pediatrics, University Hospital, Pisa, Italy
| | - G Carlucci
- OPT S.P.A., Soluzioni Per Il Mondo Healthcare, Milan, Italy
| | - E Freri
- Department of Pediatric Neuroscience, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - M R Giuca
- Unit of Pediatric Dentistry, Department of Surgical Medical Molecular Pathology and Critical Area, Dental and Oral Surgery Clinic, University of Pisa, Pisa, Italy
| | - V Guarnieri
- Division of Medical Genetics, Fondazione IRCCS Casa Sollievo della Sofferenza, Foggia, Italy
| | - G Navarra
- OPT S.P.A., Soluzioni Per Il Mondo Healthcare, Milan, Italy
| | - B Toschi
- Section of Medical Genetics, Department of Medical and Oncological Area, University Hospital, Pisa, Italy
| | - S Mora
- Laboratory of Pediatric Endocrinology, Department of Pediatrics, IRCCS San Raffaele Hospital, Milan, Italy.
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4
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Rush E, Brandi ML, Khan A, Ali DS, Al-Alwani H, Almonaei K, Alsarraf F, Bacrot S, Dahir KM, Dandurand K, Deal C, Ferrari SL, Giusti F, Guyatt G, Hatcher E, Ing SW, Javaid MK, Khan S, Kocijan R, Lewiecki EM, Linglart A, M'Hiri I, Marini F, Nunes ME, Rockman-Greenberg C, Roux C, Seefried L, Starling SR, Ward L, Yao L, Brignardello-Petersen R, Simmons JH. Proposed diagnostic criteria for the diagnosis of hypophosphatasia in children and adolescents: results from the HPP International Working Group. Osteoporos Int 2024; 35:1-10. [PMID: 37982855 PMCID: PMC10786745 DOI: 10.1007/s00198-023-06843-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 06/23/2023] [Indexed: 11/21/2023]
Abstract
Hypophosphatasia (HPP) is a rare inborn error of metabolism that presents variably in both age of onset and severity. HPP is caused by pathogenic variants in the ALPL gene, resulting in low activity of tissue nonspecific alkaline phosphatase (TNSALP). Patients with HPP tend have a similar pattern of elevation of natural substrates that can be used to aid in diagnosis. No formal diagnostic guidelines currently exist for the diagnosis of this condition in children, adolescents, or adults. The International HPP Working Group is a comprised of a multidisciplinary team of experts from Europe and North America who have expertise in the diagnosis and management of patients with HPP. This group reviewed 93 papers through a Medline, Medline In-Process, and Embase search for the terms "HPP" and "hypophosphatasia" between 2005 and 2020 and that explicitly address either the diagnosis of HPP in children, clinical manifestations of HPP in children, or both. Two reviewers independently evaluated each full-text publication for eligibility and studies were included if they were narrative reviews or case series/reports that concerned diagnosis of pediatric HPP or included clinical aspects of patients diagnosed with HPP. This review focused on 15 initial clinical manifestations that were selected by a group of clinical experts.The highest agreement in included literature was for pathogenic or likely pathogenic ALPL variant, elevation of natural substrates, and early loss of primary teeth. The highest prevalence was similar, including these same three parameters and including decreased bone mineral density. Additional parameters had less agreement and were less prevalent. These were organized into three major and six minor criteria, with diagnosis of HPP being made when two major or one major and two minor criteria are present.
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Affiliation(s)
- Eric Rush
- Division of Clinical Genetics, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO, USA.
- Department of Pediatrics, University of Missouri - Kansas City School of Medicine, 2401 Gillham Road, Kansas City, MO, USA.
- Division of Endocrinology, Metabolism, Osteoporosis, and Genetics, Department of Internal Medicine, University of Kansas School of Medicine, Kansas City, KS, USA.
| | - Maria Luisa Brandi
- F.I.R.M.O. Italian Foundation for the Research on Bone Diseases, Florence, Italy
- Donatello Bone Clinic, Villa Donatello Hospital, Florence, Italy
| | - Aliya Khan
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, Canada
| | - Dalal S Ali
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, Canada
| | - Hatim Al-Alwani
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, Canada
| | - Khulod Almonaei
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, Canada
| | - Farah Alsarraf
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, Canada
| | - Severine Bacrot
- Department of Genetics, Centre Hospitalier de Versailles, Hôpital André Mignot, Versailles, France
| | - Kathryn M Dahir
- Division of Endocrinology and Metabolism, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Karel Dandurand
- Department of Medicine, Endocrinology and Metabolism, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Chad Deal
- Center for Osteoporosis and Metabolic Bone Disease, Department of Rheumatology, The Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Serge Livio Ferrari
- Division of Bone Diseases, Department of Internal Medicine Specialties, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Francesca Giusti
- Donatello Bone Clinic, Villa Donatello Hospital, Florence, Italy
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Erin Hatcher
- Neuromuscular Clinic, McMaster University Medical Centre, Hamilton Health Sciences, Hamilton, Canada
| | - Steven W Ing
- Division of Endocrinology, Diabetes, & Metabolism, Ohio State University Wexner Medical Center, Columbus, USA
| | - Muhammad Kassim Javaid
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sarah Khan
- Bone Research and Education Centre, Oakville, ON, Canada
| | - Roland Kocijan
- 1st Medical Department, Ludwig Boltzmann Institute of Osteology at Hanusch Hospital of OEGK and AUVA, Trauma Centre Meidling, Hanusch Hospital, 1140, Vienna, Austria
| | - E Michael Lewiecki
- New Mexico Clinical Research & Osteoporosis Center, Albuquerque, NM, USA
| | - Agnes Linglart
- APHP, Bicêtre Paris-Sud, University Paris Sud, Paris-Saclay, Le Kremlin Bicêtre, Paris, France
| | - Iman M'Hiri
- Bone Research and Education Centre, Oakville, ON, Canada
| | - Francesca Marini
- F.I.R.M.O. Italian Foundation for the Research on Bone Diseases, Florence, Italy
| | - Mark E Nunes
- Division of Medical Genetics and Metabolism, Valley Children's HealthCare, Madera, CA, USA
| | | | - Christian Roux
- Rheumatology Department, Hospital Pasteur 2 CHU, 06000, Nice, France
- Inserm, CNRS, iBV, Université Côte d'Azur, 06000, Nice, France
| | - Lothar Seefried
- Musculoskeletal Center Wuerzburg, University of Wuerzburg, Wuerzburg, Germany
| | - Susan R Starling
- Division of Clinical Genetics, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO, USA
| | - Leanne Ward
- Children's Hospital of Eastern Ontario, Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Liang Yao
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | | | - Jill H Simmons
- Division of Endocrinology and Metabolism, Vanderbilt University Medical Center, Nashville, TN, USA
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Kim SM, Korkmaz F, Sims S, Ryu V, Yuen T, Zaidi M. Musculoskeletal and neurocognitive clinical significance of adult hypophosphatasia. Osteoporos Sarcopenia 2023; 9:115-120. [PMID: 38374822 PMCID: PMC10874721 DOI: 10.1016/j.afos.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 12/03/2023] [Accepted: 12/12/2023] [Indexed: 02/21/2024] Open
Abstract
Hypophosphatasia (HPP), also called Rathbun disease, is a rare genetic disorder that is caused by the loss-of-function mutation in the ALPL gene encoding tissue non-specific alkaline phosphatase. Doctor Rathbun first described the case of a 3-week-old infant who presented with severe osteopenia, rickets, and multiple radiographic fractures, and died shortly after of epileptic seizure and respiratory distress. The term "hypophosphatasia" was coined as the patients' alkaline phosphatase levels were significantly low. Since then, our understanding of HPP has evolved, and now we appreciate causative genetic mutation and the broad spectrum of clinical presentation depending on the age of onset, severity, and skeletal involvement: perinatal, infantile, childhood, adult and odontohypophosphatasia. The new development of enzyme replacement with asfostase alfa has saved the lives of severe form of hypophosphatasia. However, it is still unclear and remains challenging how to manage adult HPP that often presents with mild and non-specific symptoms such as muscle pain, joint stiffness, fatigue, anxiety, or low bone mass, which are common in the general population and not necessarily attributed to HPP. In this review, we will present 3 unique cases of adult HPP and discuss the pathophysiology, clinical presentation particularly neuromuscular and neurocognitive symptoms and management of adult HPP.
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Affiliation(s)
- Se-Min Kim
- Center for Translational Medicine and Pharmacological Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Funda Korkmaz
- Center for Translational Medicine and Pharmacological Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Steve Sims
- Center for Translational Medicine and Pharmacological Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Vitaly Ryu
- Center for Translational Medicine and Pharmacological Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Tony Yuen
- Center for Translational Medicine and Pharmacological Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mone Zaidi
- Center for Translational Medicine and Pharmacological Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Riancho JA. Diagnostic Approach to Patients with Low Serum Alkaline Phosphatase. Calcif Tissue Int 2023; 112:289-296. [PMID: 36348061 DOI: 10.1007/s00223-022-01039-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 10/26/2022] [Indexed: 11/09/2022]
Abstract
Increased serum levels of alkaline phosphatase (ALP) are widely recognized as a biochemical marker of many disorders affecting the liver or bone. However, the approach for patients with low ALP phosphatase is not well-established. Low serum ALP is an epiphenomenon of many severe acute injuries and diseases. Persistently low serum ALP may be secondary to drug therapy (including antiresorptives) or a variety of acquired disorders, such as malnutrition, vitamin and mineral deficiencies, endocrine disorders, etc. Hypophosphatasia, due to pathogenic variants of the ALPL gene, which encodes tissue non-specific ALP, is the most common genetic cause of low serum ALP. Marked bone hypomineralization is frequent in severe pediatric-onset cases. However, adult forms of hypophosphatasia usually present with milder manifestations, such as skeletal pain, chondrocalcinosis, calcific periarthritis, dental problems, and stress fractures. The diagnostic approach to these patients is discussed. Measuring several ALP substrates, such as pyrophosphate, pyridoxal phosphate, or phosphoethanolamine, may help to establish enzyme deficiency. Gene analysis showing a pathogenic variant in ALPL may confirm the diagnosis. However, a substantial proportion of patients show normal results after sequencing ALPL exons. It is still unknown if those patients carry unidentified mutations in regulatory regions of ALPL, epigenetic changes, or abnormalities in other genes.
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Affiliation(s)
- Jose A Riancho
- Departamento de Medicina y Psiquiatría, Universidad de Cantabria, Servicio de Medicina Interna, Hospital UM Valdecilla-IDIVAL, Av Valdecilla sn, 39008, Santander, Spain.
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7
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Feurstein J, Behanova M, Haschka J, Roetzer K, Uyanik G, Hadzimuratovic B, Witsch-Baumgartner M, Schett G, Zwerina J, Kocijan R. Identifying adult hypophosphatasia in the rheumatology unit. Orphanet J Rare Dis 2022; 17:435. [PMID: 36514157 PMCID: PMC9749273 DOI: 10.1186/s13023-022-02572-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 11/20/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The most frequent manifestation in adult hypophosphatasia (HPP) is musculoskeletal pain. The unspecific nature of its clinical presentation may prevent correct diagnosis. The aim of the study was to assess the prevalence of ALPL mutations in adult patients treated in rheumatological outpatient facilities with evident musculoskeletal symptoms typical for HPP. METHODS Over a period of 10 years 9,522 patients were screened in the rheumatology outpatient clinic of the Hanusch hospital Vienna. Serum ALP levels ≤ 40 U/L were found in 524 patients. After screening for secondary causes, 73 patients were invited for clinical evaluation. Genetic testing was performed in 23 patients with suspected HPP. Logistic regression models with Firth penalisation were used to estimate the unadjusted and BMI-adjusted association of each clinical factor with HPP. RESULTS Mutations in the ALPL gene were observed in 57% of genetically screened patients. Arthralgia, fractures, and pain were the leading symptoms in individuals with ALPL mutation. Chondrocalcinosis (OR 29.12; 95% CI 2.02-1593.52) and dental disease (OR 8.33; 95% CI 0.93-143.40) were associated with ALPL mutation, independent of BMI. Onset of symptoms in patients with ALPL mutation was at 35.1 (14.3) years, with a mean duration from symptoms to diagnosis of 14.4 (8.1) years. Bone mineral density (BMD) and trabecular bone score (TBS) as well as bone turnover markers were not indicative for HPP or ALPL mutation. CONCLUSION HPP can mimic rheumatologic diseases. Thus, HPP should be considered as a possible diagnosis in adult patients presenting with musculoskeletal pain of unknown origin in rheumatology outpatient clinics. In patients with persistently low ALP serum levels and unclear musculoskeletal pain, HPP as the underlying cause has to be considered.
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Affiliation(s)
- Julia Feurstein
- grid.413662.40000 0000 8987 0344Ludwig Boltzmann Institute of Osteology at Hanusch Hospital of OEGK and AUVA Trauma Centre Meidling, 1St Medical Department, Hanusch Hospital, Heinrich-Collin-Strasse 30, 1140 Vienna, Austria ,grid.413662.40000 0000 8987 03441St Medical Department, Hanusch Hospital Vienna, Vienna, Austria
| | - Martina Behanova
- grid.413662.40000 0000 8987 0344Ludwig Boltzmann Institute of Osteology at Hanusch Hospital of OEGK and AUVA Trauma Centre Meidling, 1St Medical Department, Hanusch Hospital, Heinrich-Collin-Strasse 30, 1140 Vienna, Austria
| | - Judith Haschka
- grid.413662.40000 0000 8987 0344Ludwig Boltzmann Institute of Osteology at Hanusch Hospital of OEGK and AUVA Trauma Centre Meidling, 1St Medical Department, Hanusch Hospital, Heinrich-Collin-Strasse 30, 1140 Vienna, Austria ,grid.413662.40000 0000 8987 03441St Medical Department, Hanusch Hospital Vienna, Vienna, Austria ,Vienna Bone and Growth Centre, Vienna, Austria
| | - Katharina Roetzer
- grid.413662.40000 0000 8987 0344Centre for Medical Genetics, Hanusch Hospital Vienna, Vienna, Austria ,grid.263618.80000 0004 0367 8888Medical Faculty of Genetics, Sigmund Freud University, Vienna, Austria
| | - Gökhan Uyanik
- grid.413662.40000 0000 8987 0344Centre for Medical Genetics, Hanusch Hospital Vienna, Vienna, Austria ,grid.263618.80000 0004 0367 8888Medical Faculty of Genetics, Sigmund Freud University, Vienna, Austria
| | - Benjamin Hadzimuratovic
- grid.413662.40000 0000 8987 03441St Medical Department, Hanusch Hospital Vienna, Vienna, Austria
| | - Martina Witsch-Baumgartner
- grid.5361.10000 0000 8853 2677Division Human Genetics, Department of Medical Genetics, Molecular and Clinical Pharmacology, Medical University Innsbruck, Innsbruck, Austria
| | - Georg Schett
- grid.5330.50000 0001 2107 3311Department of Internal Medicine 3, The University Clinic of Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Jochen Zwerina
- grid.413662.40000 0000 8987 0344Ludwig Boltzmann Institute of Osteology at Hanusch Hospital of OEGK and AUVA Trauma Centre Meidling, 1St Medical Department, Hanusch Hospital, Heinrich-Collin-Strasse 30, 1140 Vienna, Austria ,grid.413662.40000 0000 8987 03441St Medical Department, Hanusch Hospital Vienna, Vienna, Austria ,Vienna Bone and Growth Centre, Vienna, Austria
| | - Roland Kocijan
- grid.413662.40000 0000 8987 0344Ludwig Boltzmann Institute of Osteology at Hanusch Hospital of OEGK and AUVA Trauma Centre Meidling, 1St Medical Department, Hanusch Hospital, Heinrich-Collin-Strasse 30, 1140 Vienna, Austria ,grid.413662.40000 0000 8987 03441St Medical Department, Hanusch Hospital Vienna, Vienna, Austria ,Vienna Bone and Growth Centre, Vienna, Austria ,grid.263618.80000 0004 0367 8888Medical Faculty of Bone Diseases, Sigmund Freud University, Vienna, Austria
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Abstract
The foundation of bone health is established in utero. Bone accrual starts from the developing fetus and continues throughout childhood and adolescence. This process is crucial to achieve peak bone mass. Understanding factors that influence bone accrual before attainment of peak bone mass is thus critical to improve bone health and prevent osteoporosis, thereby reducing the burden of osteoporotic fractures in older women. In this review, we broadly outline factors influencing peak bone mass from pregnancy to infancy, childhood and adolescence with potential diseases and medications that may affect the optimum trajectory to maximizing bone health. It is estimated that a 10% increase in peak bone mass will delay the onset of osteoporosis by 13 years in a woman.
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Affiliation(s)
- R F Vasanwala
- KK Women's and Children's Hospital, Singapore, Singapore
| | - L Gani
- Changi General Hospital, Singapore, Singapore
| | - S B Ang
- KK Women's and Children's Hospital, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore.,Lee Kong Chian School of Medicine, Singapore, Singapore
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