Handle with care

Program helps identify and prevent injuries to children with brittle bones

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Winnipeg Health Region
Wave, July / August 2012

A Winnipeg Health Region team has created a first-of-its-kind tool kit to help identify children in hospital who are at risk for osteoporosis and possible bone fractures.

The kit was developed by the Pediatric Bone Health Project (PBHP) team at the Children's Hospital as part of its Fragile - Handle With Care protocol.

In addition to providing a screening tool and guidelines for assessment, prevention and treatment, the kit, produced with financial support from the Children's Hospital Foundation, also includes a family and caregiver guide for children at risk.

Sandy Taylor, a clinical research nurse with the PBHP, says the tool kit is unique. "As far as I know, no other pediatric health care centre has this type of program," says Taylor. "The Children's Hospital of Philadelphia screens their neo-natal infants, but doesn't do the same for older children and teenagers the way we do."

While osteoporosis is commonly associated with older patients, it can be an issue for younger patients as well, according to Taylor and Nicole Kirouac, who is a pediatric endocrine nurse clinician at Children's Hospital and a member of the PBHP team.

Certain medications, nutrient deficiencies or mobility issues can lead to low bone mass, which is a characteristic of osteoporosis. This leads to increased bone fragility and risk of fracture. The new resources will allow health-care providers to identify children at risk for developing osteoporosis and fragility fractures, and prevent potential injury.

"Our bone health screening tool and algorithm flags children upon admission to hospital in six areas: the four medical units, the surgical unit and the pediatric intensive care unit," says Taylor.

Since the team started collecting data last November, it has identified about 50 children with the potential for osteoporosis out of more than 1,000 admissions.

"Thanks to our screening tool, and our Fragile - Handle With Care protocol in place, none of those children have sustained a fracture," she says.

Children who are admitted to hospital with a known diagnosis of osteoporosis or who are known to display certain characteristics are immediately flagged for further assessment, preventive measures and treatment. Children with certain medical conditions or dietary deficiencies are also noted, but do not necessarily go into the treatment plan because their condition is not as critical.

To help identify children at risk, the project team developed a sticker with the image of a mascot - Ostey, the "Osteosaurus" Dinosaur - which can be placed on signs at a child's bedside, on medical charts and on requisitions for care by other departments in the hospital, such as the CT scanning or physiotherapy departments. "We use posters and stickers to identify these children, to alert people to handle them with extra care. For example, if a person is taking a blood sample, they can't pull on the child's arm to straighten it, or they might break it," says Taylor. "This protocol is also communicated to the parents and other caregivers, like day cares and schools."

The bone health project is one example of how the Region and its staff members are continually looking for ways to improve the quality of care and enhance patient safety, says Taylor. In addition to raising awareness about children at risk within the hospital, the team has also partnered with the Osteoporosis Society of Canada (Manitoba Chapter) and has adopted its prevention pamphlet. The PBHP has also produced its own booklet for parents and caregivers that provides information on what can be done at home to keep osteoporosis from developing. This includes ensuring children eat a healthy diet and receive adequate levels of calcium and Vitamin D to build up bones.

The PBHP team has been spreading the word about their program to institutions such as the St. Amant Centre, the Rehabilitation Centre for Children, Manitoba Home Care and the URIS School Nurses. Their next goal is to introduce the Fragile - Handle With Care protocol to primary care physicians throughout the province and continue to educate the community pediatricians. They have also presented this project through presentations and poster sessions internationally throughout Canada, Europe and the United States.

Taylor says it all comes down to keeping kids safe from the bad breaks of osteoporosis, in hospital or at home. "Kids just want to be kids," she says. "We want to help them do that safely."

Susie Strachan is a communications advisor with the Winnipeg Health Region.

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Who is at risk

The Pediatric Bone Health Project's screening tool flags children in three separate categories. Children in the first two categories start the Fragile - Handle With Care protocol, while children in the third category undergo further testing to determine if they are at risk. The categories are:

  1. Children with a known diagnosis of osteoporosis, or osteogenesis imperfecta.
  2. Children with a history of having fractures from minor trauma, like breaking a bone when falling from standing height. This category also includes children two years of age or older who haven't been able to walk for more than three months, and also children under two years of age who were not sitting by nine months and not walking by 18 months. Lack of mobility impedes the development of strong bones.
  3. Children who have a medical condition that may affect their bone density, like cancer or leukemia, anorexia nervosa, cerebral palsy, chronic kidney disease, cystic fibrosis, Duchene muscular dystrophy or amenorrhea. Also in this category are children who have undergone a transplant for any organ or tissue, children who are on seizure medication, have undergone a steroid treatment lasting longer than three months in the past year, and children who have a known Vitamin D deficiency.

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Special treatment for kids

Children who have been identified as being at risk for fractures are flagged and receive special treatment while in hospital. This includes:

  • Bedside signs and stickers on their chart, reminding health-care staff to handle the children with extra care.
  • Consultation with nutritionists about diet, including the amount of calcium and Vitamin D they need to take.
  • Consultations with physiotherapists and occupational therapists, to help caregivers learn how to handle their fragile child safely, and types of physical activity their child can safely enjoy.
  • DXA scans, if the child is older than four years of age, with a consultation with an endocrinologist if considering bone-building medications only. A DXA scan (Dual-energy X-ray absorptiometry) is a method of measuring bone density.
  • Education for parents and other caregivers, including receiving the prevention pamphlet.
  • Follow up with the child's primary care team and family doctor.


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