Association between bone density and fractures in children: A systematic review and meta-analysis

OBJECTIVE. The objective of this article was to systematically review all published studies that investigated the association between bone density and fractures in children. DESIGN. Potentially relevant articles were identified by searching electronic databases. Duplicates were removed, abstracts were inspected, and relevant articles were obtained. Studies were included in the systematic review if participants were < 16.0 years old, were healthy, had extractable data on bone mass, and had fractures as the outcome. RESULTS. Ten case-control studies were identified. No prospective studies were found. There was no evidence of heterogeneity between studies or of funnel-plot asymmetry. Eight of the studies were included in the meta-analysis, because they presented results as means and standard deviations of bone density in cases and controls. The pooled standardized mean difference for bone mass in children with and without fractures, from a fixed-effects model, was -0.32 (95% confidence interval: -0.43 to -0.21). CONCLUSIONS. Evidence for an association between bone density and fractures in children is limited. The results from this meta-analysis suggest that there is an association between low bone density and fractures in children. Although there was no evidence of heterogeneity or publication bias, this meta-analysis is based on case-control studies that are prone to bias. Large, well-conducted prospective cohort studies are required to confirm the association between bone density and fractures in children.