Diagnosis and management of bone fragility fractures in children and adolescents: Good Clinical Practice Recommendations of the Italian Society of Pediatric Endocrinology and Diabetology (ISPED)

Abstract

Fragility fractures in children and adolescence represent a clinically relevant and potentially under-recognized condition that may reflect an underlying impairment of bone strength due to primary or secondary causes. Despite their potential impact on growth, quality of life, and long-term skeletal health, the identification and management of pediatric bone fragility remain heterogeneous, largely due to the lack of guidelines and the limited availability of high-quality pediatric evidence. To address this gap, a multidisciplinary panel of experts from the Italian Society of Pediatric Endocrinology and Diabetology, in collaboration with other national scientific societies developed Good Clinical Practice Recommendations for the diagnosis and management of children and adolescents with fragility fractures. The development process followed the methodological framework of the Italian National Guideline System and was based on a systematic literature review and the GRADE methodology. Four key clinical questions were addressed: (1) the role of dual-energy X-ray absorptiometry (DXA) in predicting the fracture risk; (2) the use of next-generation sequencing (NGS) for the diagnosis of primary bone fragility; (3) the effectiveness of bisphosphonates in reducing fracture risk and improving clinical outcomes; and (4) the role of calcium and vitamin D supplementation in fracture prevention. These recommendations, revised and approved by the Italian National Institute of Health (INIH), aim to provide clinicians with a structured and evidence-based approach to improve the early identification, diagnostic work-up, and management of pediatric patients with bone fragility, promoting standardized care and reducing variability in clinical practice.