J Clin Endocrinol Metab 45: 845, 1977 Decreased Cortical Thickness & Osteopenia in Children with Diabetes Mellitus J. V. SANTIAGO, W. H. McALISTER, S. K. RATZAN, Y. BUSSMAN, M. W. HAYMOND, G. SHACKELFORD, AND V. V. WELDON Departments of Pediatrics and Radiology, Washington University School of Medicine, St. Louis, Missouri 63110 ABSTRACT. A recent study using the photon absorption technique has revealed a high frequency of significant bone loss in diabetic adults regardless of age or duration of diabetes. In this study 107 diabetic children age 4-18 were studied using cortical bone thickness and skeletal maturation as indicators of bone development. Overall, 25% of all diabetic children had cortical thickness values below the five percent limit for normal children. This was more common in boys than girls and was unrelated to duration of diabetes. A modest increase in delayed skeletal maturation did not account for the cortical thinning and osteopenia observed. The cause of the osteopenia of diabetic children remains an enigma. Introduction. Osteopenia was first described in association with diabetes mellitus by Albright et al. in 1949(1). Although hip fractures and osteopenia are known to be more common in elderly diabetics(2), the true incidence of osteopenia in diabetes has probably been underestimated in the past because standard radiographic viewing is relatively insensitive for detecting significant loss of bone density. Levin et al.(3), using the more sensitive photon absorption technique(4), have found a 60% prevalence rate of decreased bone density among 136 diabetics, most of whom were above age 18. These investigators suggested that loss of bone density was unrelated to the severity or duration of diabetes. We have studied cortical bone thickness and bone maturation in 107 children with insulin-requiring diabetes to determine if these indicators of bone development are abnormal in childhood diabetes mellitus. Methods. Cortical bone thickness and percent cortical area (PCA) were measured by the method of Gam(5) at the midshaft of the second metacarpal bone and compared to normal age and sex-matched values for healthy white children in the midwestern United States. Fifty children age 5-16 with recent hand or wrist trauma were Submitted April 29, 1977

studied to determine if Garn's normal values were applicable to a St. Louis population. All had cortical bone thickness diameters within the 5 and 95 percentile limits of Garn's values. Bone maturation, expressed as bone age, was estimated in hand films by the method of Greulich and Pyle (6), and compared to their normal age and sex-matched values for white boys up to age 18 and girls up to age 16. The 107 insulin-requiring diabetics were evaluated as part of the Diabetes Registry Program of the Washington University Diabetes and Endocrinology Center. No patient had been in ketoacidosis during the previous 3 months, and all were taking insulin. Mean age was 11.9 years (range 4^ to 18); mean duration of diabetes was 4.8 years (range 0.4 to 13 years); 61 were females, and 46 were males; 81% were white, and 19% were black. All patients had a normal serum thyroxine concentration and a growth velocity of greater than 5 cm per year during the previous 6 months. Results. Cortical thickness for the diabetic boys and girls is shown in Fig. 1 and is compared to the trendline of a comprehensive study of normal whites in Ohio(5). Among the 61 girls, 75% fell below the mean and 13% below the 5 percentile limit for age adjusted normal values. Among the 46 males, 87% fell below the mean for

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