The Get Healthy Tampa Bay Podcast

E84: Building Stronger Futures 💪🏼 Pediatric Bone Health Discussion with Dr. Maureen Maciel

• Kerry Reller

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Welcome to the Get Healthy Tampa Bay Podcast with Dr. Kerry Reller! This week, I'm joined by Dr. Maureen Maciel, a pediatric orthopedic surgeon specializing in neuro musculoskeletal conditions. In this episode, we delve into the world of pediatric bone health, discussing everything from common fractures in children to the importance of building optimal bone mass early in life. Dr. Maciel shares her insights on the effects of nutrition, exercise, and obesity on bone health, as well as preventative strategies to ensure our kids grow up strong and healthy. Tune in to learn invaluable tips for fostering robust bone development in children.

Maureen Maciel, MD, is a board certified pediatric orthopedic surgeon, practicing in Tampa, Florida. After graduating from the University of Minnesota, Dr. Maciel received her medical degree from Mount Sinai Medical School. She went on to complete an orthopedic surgery residency at The Ohio State University and a pediatric orthopedic surgery fellowship at Shriner’s Hospital for Children in Tampa. For 16 years, she was at Shriners Hospital for Children where she served as Chief of Staff and specialized in the treatment of children with rare diseases. A highly experienced clinician, Dr. Maciel also served as an assistant professor at the University of South Florida in the department of orthopedics and sports medicine for more than 14 years.

0:00 - Introduction to Dr. Maureen Maciel and Pediatric Orthopedics
1:29 - Journey into Orthopedics: A Surprising Career Path
3:38 - The Resilience of Pediatric Patients and Their Recovery
4:20 - Comparing Pediatric and Adult Fractures
7:05 - The Critical Role of Bone Health Starting in Childhood
12:48 - Nutritional Recommendations for Enhancing Pediatric Bone Health
16:02 - Vitamin D's Role in Bone Integrity and Health
22:26 - Athletic Activities and Bone Health: A Delicate Balance
29:32 - Obesity and Its Impact on Pediatric Bone Health
37:01 - Owning the Bone: Strategies for Optimal Pediatric Bone Health

Connect with Dr.Maureen
Facebook: https://web.facebook.com/MaureenMacielMD?_rdc=1&_rdr
LinkedIn: https://www.linkedin.com/in/maciel-maureen-913665b9/
Youtube: https://www.youtube.com/channel/UCL2m4jWutMzL16jMua-W9iA
Website: https://www.maureenmaciel.com/maureen-j-maciel-md-pediatric-orthopedic-surgeon-tampa-fl/

Connect with Dr. Kerry Reller
Podcast website: https://gethealthytbpodcast.buzzsprou... 
My linktree: linktr.ee/kerryrellermd
Follow on Facebook: / clearwaterfamilymedicine  
Follow on Instagram: / clearwaterfamilymedicine  
Clearwater Family Medicine and Allergy website: https://sites.google.com/view/clearwa...
Podcast: https://gethealthytbpodcast.buzzsprou... 

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Kerry:

All right. Hi, everybody. Welcome back to the Get Healthy Tampa Bay podcast. I'm your host, Dr. Kerry Reller. And dr. Maureen has a M A C I E L. So how do I say that? Maciel? I have asked you that first. Maciel. Okay. Very good. I'm so sorry. So why don't you tell us a little about who you are and what you do?

Maureen:

I am a pediatric orthopedic surgeon. So I take care of children with all sorts of neuro musculoskeletal conditions, which for my particular line of interest includes patients with metabolic bone disease, brittle bone disease, as well as limb deficiencies and bone differences. But I also see as we all do pediatric fractures. So I see a lot of patients who have sort of low energy and high energy fractures and provide that fracture care as well.

Kerry:

So how did you kind of get into orthopedics? Did you always want to go into orthopedics or, and especially for kids too? How'd you get into that?

Maureen:

So I did not know that I wanted to give it to orthopedics. I went to med school originally thinking, you know, I really like infectious disease. And maybe that would be something more genetics. But as I progressed through my rotations, I found out that I really enjoyed being in multiple different environments. I liked that I could be in the ER, in the OR, in the clinic, within the surgical specialties. And then I rotated with orthopedics and One of the things I love about orthopedics is that not only are we working with children specifically to, you know, how they move, how they're able muscular or skeletal conditions affect movement and function, but as an orthopedic surgeon, it's a pretty, it's a physical specialty. So you are working yourself oftentimes physically to provide care, whether you're putting casts on or performing surgery. And I was really drawn to that. So that kind of sealed the deal with orthopedics. Then when it came to pediatric orthopedics I was really inspired by the pediatric population. Kids just want to get better. And so they're so motivated by Doing what they love to do that, that really promotes their recovery from either surgeries or fractures. And, you know, very rarely do they need physical therapy for, you know, minor injuries. And they're usually not interested in medication. They just want to get going. And as soon as they feel better, they'll do whatever they need to do. So I found that, you know, it was really rewarding. You're not, you're not trying to pull that recovery out of them. They're, you know, often, you have to slow them down if anything. So that really drew me in.

Kerry:

Yeah, that's really neat. I think we're totally opposites. Cause I like can't stand the OR and the ER and all that stuff, but I'm thankful that everybody has different interests, right?

Maureen:

Yeah, yeah, definitely.

Kerry:

and I think you're right. Like kids want to get better and get back to where they were. And I think that drives them and luckily they do heal better most of the time, right? Yeah,

Maureen:

when I talk to my adult colleagues, I am grateful for young, typically, you know, most of my fracture patients, we're talking young, healthy bone, healthy tissues. And that has a lot to do with how they heal. So our goal is to make sure that they stay healthy.

Kerry:

absolutely. We'll speak a little bit about that. So what is the differences then between an adult with a fracture and a pediatric patient with a fracture and what are like the risks, I guess, for where the fracture might occur in a kid?

Maureen:

So one of the really interesting things that sets pediatric apart is there are different locations of fracture that are more common in pediatrics, the forearm and the elbow are big ones. And those are typically, you know, the monkey bars take down quite a few children. And that's usually they're falling onto their outstretched arm. They're trying to catch themselves and then they have a fracture. And, it's not always surgical. In fact, fractures in children are by and large not surgical because children's bones want to heal and between the really thick coating that surrounds a pediatric bone, in addition with the growth plate, which is, putting down new bone every day, even a pretty severely angulated fracture can heal and then slowly as the bone grows, the normal contour is restored. So we can accept a certain amount of what we call angulation or displacement of the two bones. You know, they don't look perfect. For certain fractures, you know, that, that can be accepted. And then over time, the bone heals, regrows, and grows right back into its normal alignment. So that, I think, is what really sets pediatric fractures apart. And then I think that the other piece of it is, bone fragility. Pediatric fractures usually occur for reasons, you know, higher energy injuries. A fall from a standing position or fall from standing level or ground level falls, as we call them, do not typically result in fractures in kids. If they're running and they trip, you know, that's one thing, but usually it takes more energy because the bones are stronger. However, we're learning over time that we have to pay more attention to pediatric bone health. And we've seen our adult colleagues are doing this really well. Our adult orthopedists in the American Academy of Orthopedic Surgery have an Own the Bone program. So the adult orthopedists have decided that, you know, they really need to own that conversation and to push the initiatives to improve adult bone health to prevent osteoporosis and to prevent osteoporosis related fractures. And so there's a lot of work happening in the adult world to push those measures forward. And I think that's a great part because, the socioeconomic burden of osteoporosis related fractures is massive,

Kerry:

Mm hmm.

Maureen:

can have a significant increase in mortality in a patient who has a hip fracture, who has a few medical problems, but that can be a setup for, you know, a major hospital stay and, you know, be life threatening. And I think that, in children, we kind of haven't seen that size initiative coming forward yet. What we have to talk about and what we have to share is that osteoporosis begins in childhood. So by the time we're at the end of our second decade, right around that time, we have built peak bone mass. And so, by the time you're 20, that's your peak bone mass. And like many things after that, it kind of all goes downhill from there. So from 20 to 50, bone mass stays fairly steady in a plateau. And then starting at 50, it decreases. So if we're not optimizing a child's bone mass and getting them to their, you know, their potential peak bone mass in their late teens by the time they're 20, then we've lost that opportunity. And I think that that's where You know, kind of drawing it all back from that, we're concerned about these fragility fractures in 60 year olds, 70 year olds, but we're setting them up for that if we're not paying attention to their bone health when they're 12, 15, 17, 20. So I think that as pediatric orthopedists, we need to do a better job of owning the bone and saying, okay, this is our job. Our job to talk to our patients and families anytime somebody comes in for a fracture or an injury or it's a, you know, non injury related visit. It's a regular visit. We have to start having that conversation and making bone health part of the culture of the office. So, you know, I'm sure and even in your office, you have staff and you rely on staff to understand what you're doing and jump in and provide information. So our M. A. s, our Cast Techs, we have a lot of staff in Ortho who spend a fair amount of time with patients you know, putting on a cast takes a while. So it's a great opportunity to have an office culture where we're all focused on bone health and we're sharing that information with our patients.

Kerry:

Yeah. I mean, I love that. Preventative health really does start at earlier ages. Like we miss things if we aren't and where we don't see the patients coming in sooner. And like for sometimes we talk about dementia and, you know, the dementia risks. are really like for midlife and earlier, right? That you could be not eating and doing things in the right way. And that can make your risk for dementia later. But I actually am learning today, obviously that I didn't know that the bone health was so dependent upon your earlier years. So that's great. It's so important to get that word out. So what do they do with, you know, own the bone for adults that we could, you know, translate into the pediatric population?

Maureen:

the adult population the focus is on education and then a lot of changes in sort of various disciplines in society. So we're looking at reaching not just physicians, but caregivers at all levels and trying to have that conversation. And orthopedists have sort of taken on the push for that. In children, I think that that conversation is sort of falling in the chasm betweeou Pediatricians and orthopedists. So we may see a child for a fracture and the whole care of that fracture may be two visits. But with me, I see the patient after they've been at urgent care or the ER and they come and so we do a definitive diagnosis and discuss and place a cast five weeks later, the patient comes back, we remove the cast, take an X ray, great, you're healed, you're done, you don't need anything else. If that patient, you know, has another fracture a few months later, maybe they see me, maybe they're seeing somebody else, and then six months later is their well child visit with their pediatrician, it may not come to mind for the parent to say, oh, by the way, we had two fractures this year. So the pediatrician doesn't really get the opportunity to have that sort of little, you know, flashing light go off, like, okay, maybe there's something going on. Okay. Whereas the orthopedist, you know, we have the opportunity to do it right then and there because you know, the child's bone has fractured. That bone now needs to heal and we need to make sure that they have all the metabolites to optimize that. So for us, I think we're actually better positioned than our adult colleagues, because unfortunately for our adult colleagues and our adult patients, they are already in a state of compromised bone mass. Whereas our kids, we can help right then and there. We can get on it and start talking about, you know, eating habits, exercise supplementation, and we can make a change.

Kerry:

So what sort of things do you, you know, recommend? I remember given my first born like vitamin D drops when she was nursing, but what, how do you start? I mean, if you're not going to start at nursing, but what are the first things that you guys would recommend and discuss?

Maureen:

So kind of just start out well, what do you know? What do you eat? Do you drink milk? Do you, you know, take in, you know, do you eat salads? Do you eat yogurt and things like that? And, you know, we have a lot of patients who are not taking in dairy or are maybe plant based diets. That's what they're doing at home. And so Even for children who don't have any dietary restrictions, getting an adequate amount of vitamin D in their diet every day is very difficult. Now, at least 50 percent of vitamin D that our body is going to synthesize should be coming from sunlight. But we're not out in the sun as much. And if we are in the sun, we're doing a good job and using our sunscreen. So we're not getting that vitamin D. I don't think we want to say, well, skip sunscreen so you can get your vitamin D. So we do have to look more closely at diet. We're really kind of, we're directed that way. So that's where I would kind of open that conversation up. And then, you know, to share that, it's hard to get all the nutrients we want through diet. Especially kind of the way that we eat in our society and probably going to need the supplement. So, you know, we want to supplement with basically the recipe of things that our bone needs. So our bone needs vitamin D, it needs calcium, it needs vitamin K and we need vitamin C. So, typically, a multivitamin will help bring some of those nutrients in, but oftentimes we need to supplement with vitamin D.

Kerry:

So what role does vitamin D play in maintaining bone health in kids?

Maureen:

So, vitamin D is an essential. element of bone health. You need vitamin D and then you need calcium to get the vitamin D into the bone. They're very interdependent and that really forms a building block for kind of the hardness of the bone, that outer coating of bone. If you look at a bone and you have like a long bone, even, you know, with a chicken, you see there's the outer portion and then there's hollow inner portion. So that The bone health of that outer portion is very dependent on having optimum levels of vitamin D. And we are still challenged a bit because there's not a great consensus on what is the optimum level. So, you know, the AAP, so the American Academy of Pediatrics and the endocrine societies that have different definitions of what is optimal vitamin D levels. And so that kind of complicates things, but I sort of trend towards the endocrine society's definitions. So, you know, you're looking at about 20 to 30 and 20 is sort of the low level of sufficient vitamin D. And 30 is kind of the midpoint 30 to 50 would be sufficient. And then it's kind of how do we get there and what does it take to get there? So,

Kerry:

the lab values, right?

Maureen:

these are the lab values. So, this is The serum vitamin D, which is not a perfect measure but it's sort of the best we have to work with right now. And like I said, you know, there's not a great consensus on what that is. And I think that that complicates a little bit, our understanding of either the incidence of vitamin D deficiency or the contribution to fracture risk. But those are, you know, what we're looking to aim for. Okay. To try and make sure that we're at least sufficient.

Kerry:

Yeah. So I think on the lab values, at least for adults, they read like 30 as the normal, but like, really, I think in reality, we all suspect that it's higher. And then the other issue is that They don't really pay for that lab job very often. So is it something that you do on kids or no?

Maureen:

No. And people sort of think differently about this. There is a study that shows that if we obtain a lab value and it's a low, then we get better compliance with supplementation than if we say, you know, you might be low, just supplement. So those who really feel like it's important, they have to have that number, you know, that can be a helpful driving force, but Blood draws in Children that's not, you know, they're not a fan of that. And so personally, I typically recommend just safe supplementation because unless I feel like the patient may have an underlying metabolic bone disease or osteoporosis, then I don't routinely get them.

Kerry:

Okay. Yeah. So what are some of the cause, common causes of vitamin D deficiency where maybe we would think of doing that test?

Maureen:

So, you know, we have two different kinds of patients. There's nutritional rickets which is a disease of insufficient bone metabolites because of poor nutritional intake of the necessary metabolites. And then we have hypophosphatemic rickets, which is secondary to a genetic mutation. And then we have where in that case vitamin D supplementation alone is not sufficient. And then we have osteoporosis and we have brittle bone diseases. So it is important when I see a patient where I suspect that there is an underlying problem, if I think that there's something that, you know, is not vitamin D dependent, then that may require a more aggressive workup. If the bone just does not seem to either be healing as fast as it should, or has a softer quality than it should, then we probably should draw a vitamin D and really understand whether or not that's the issue, or if we need to pursue something else.

Kerry:

Would those things like the rickets and the hypophosphatemia rickets, would those classify as metabolic bone diseases?

Maureen:

Yes, yes. So we have the nutritional rickets, it does, and the incidence there is about 3 to 27 in 100, 000. And that's completely nutrition dependent. Individuals at risk for that include for example, infants who are exclusively breastfeeding and not supplementing whose mothers are vitamin D insufficient, deficient, and not supplementing. So that population, would require more scrutiny. And usually there are other physical findings that drive us in that direction rather than your population of a child who's had a couple fractures, Maybe the bones not healing as fast as you would expect or, you know, on appearance or during surgery doesn't seem to have the kind of consistency and response that we would expect for a child and otherwise healthy child.

Kerry:

let me ask you. So I have this there's a guy, he hosts a model health show. I don't know if you've ever heard of it. Sean's stevenson, he, his story is that he grew up in a food desert in Ferguson, Missouri, and I think he was running track or something in high school or something like that. And because of probably poor nutrition, he had a fracture and ended his Career and then let him on this journey of pursuing the optimal health and everything that he's doing now with his profession, which is so interesting. But would you say that is probably like a nutritional cause? And what do you, I don't know, just what do you think about that? Mm

Maureen:

So, you know, vitamin D deficiency in athletes definitely puts them at risk for stress fractures and for other fractures that are just fractures of bone right underneath the joint surface or some other fractures we see in vitamin D deficiency. And you know, that is absolutely a concern you have, especially for athletes. You have to be at a point Particular level you can think about like a battery. The battery has to be fully charged between one workout and the next workout so that you're not breaking down tissue either muscle or bone and if you're not recharging that battery either because you know the patient that Individual is not getting enough sleep or not eating appropriately. If the muscles are stressed and those sort of metabolites that have built up in the muscles don't have time to flush out, those are all things that are going to drain the battery. And every time you go back to that activity, when you're depleted, you're setting yourself up for injury. So that's something that we do pay attention with our athletes. And specifically our female athletes. Because if we have high level female athletes who wind up with athletic amenorrhea, now, you know, their estrogen levels are off, and that's another component that's going to set them up for not obtaining that peak bone mass.

Kerry:

Mm hmm. Oh, yeah, absolutely. Yeah, you know, he never really specified if it was like a stress type fracture or fracture fracture. But in my head, I always like, envision him like running and then boom, having a fracture and falling over. I'm like, Oh, my gosh, what is going on?

Maureen:

happen because you can have, especially in the tibia and the lower leg bone, you can have micro fractures. And I don't recall, I think it was in basketball, there was a major athlete, you know, at the, the national level who had a horrible tibia fracture on, on TV, on national television with what seemed like, you know, a minor, you know, a jump and a land. I, I think so. My office was actually talking about it as we were discussing bone

Kerry:

My husband brought that up, but I don't remember when that was. Yeah. Oh my goodness. That's crazy. So besides vitamin D, what other factors contribute to optimal bone health? For

Maureen:

So we need to get, we need to get vitamin C. So we're either drinking a lot of orange juice or supplementing. Vitamin K. And physical exercise. I mean, definitely. So we can talk about what we put in our bodies, but you know, there's also what we do with them so that weight bearing, load bearing exercise, strength exercise. Plays a huge role. And if we can increase that activity to, you know, 20 minutes of exercise, one to two times a week, that has been shown to have a direct positive effect on bone mass. So that's another conversation we have as well as general health, because obesity, particularly in a prolonged state, Basically puts the body in this sort of inflammatory state, and that results in a downregulation of the production of bone forming cells, as well as a downregulation in the activity of those bone forming cells, upregulation of cells that take bone away, and just further perpetuate fracture risk.

Kerry:

yeah, so not only important for like weight bearing joints, but obviously the, the remake and the remodeling of the bone that occurs. Yeah, is, is important with that because of obesity and having the inflammatory effects. Okay.

Maureen:

right. And,

Kerry:

Hmm.

Maureen:

both vitamin D deficiency and obesity in childhood are independent risk factors for fracture. So when we see those together, the child is even more at risk for fracture. And another point, when you, you know, sort of talk about that bone turnover adolescents, are, when they enter what we call peak height velocity, and they're growing, they have that adolescent growth spurt that we talk about, they are attaining 90 percent of their adult height. And that bone turnover is, I mean, that's just churning to elongate the bones. So while they're at 90 percent of their mature height, they're at 57 percent of their peak bone mass. So they actually have a decrease in strength of that cortical bone during that time period. And just by nature of that are at higher risk for fracture in that adolescent growth period.

Kerry:

Yeah. I mean, from what you're saying, it's similar things that we counsel in our older population for osteoporosis too, right? Get the exercise, weight bearing activity, calcium, vitamin D. I don't think I use talking about vitamin C as much, but it sounds like we need to be. And then you mentioned vitamin K. So these are all like, Similar things, but you're

Maureen:

And that's

Kerry:

you know, prevent, do

Maureen:

And that's the thing. We just, we need to pull the continuum back to like the, you know, the beginning of the life cycle. You're doing a great job. We've got to do the peds people. We have to do our part now. We need to get ourselves into that conversation and understand that it's a continuum so we can. You know, we can do our part,

Kerry:

and then you said like vitamin D and an obesity independent of each other are risk, but we often almost always, at least in the adult population, when I do pull a vitamin D level, it's very much associated with the adult population of vitamin D and obesity. Almost everybody who suffers with obesity has vitamin D deficiency as well.

Maureen:

right? Because we know that vitamin D is a fat soluble vitamin. It gets pulled into fat cells and then it's not available in the bloodstream like it should be. And that's an interesting conversation. I don't know how you manage that on the adult side, but vitamin D Supplement guidelines are typically age-based rather than weight-based. So even with our age-based supplementation, our patients who are overweight or obese may not, may still not be getting enough vitamin D.

Kerry:

Yeah. That's a that's a really good point. I hadn't thought of it as being, you know, that makes sense, fat valuable vitamin and it gets pulled in from the tissues that, that the mechanism makes sense. Yeah. So what about like pediatric obesity complications with like, what kind of fractures are seen there or what kind of abnormalities that might come across your clinic? Yeah.

Maureen:

Yeah. I think what we're seeing are lower energy injuries, so. Where a ground level fall does result in a fracture that you would usually suspect if it was a higher, you know, energy mechanism a fall from the monkey bars or from several feet above ground level You know, they kind of think about normal kid stuff, you know, fall off the monkey bars, fall off the slide, all the other things. So, in our patients who are overweight or obese, we see fractures that are occurring with lower energy mechanisms. We're seeing fractures that wind up to, you know, more often operative. So that's one of the things with vitamin D deficiency. We have been able to determine that it does set patients up for having a higher likelihood of needing surgery. So the fracture is more severe. So that may be why we're seeing that in our overweight population is that they are vitamin D deficient, therefore the fracture is more severe and they are a higher likelihood of needing surgical intervention. I think one thing that we see in addition that may lend to all of this is that a lot of pediatric fracture care is it's casting, it's manipulation. And when we cast, we sometimes are just holding the bone in place, just, you know, protect it, let it heal. But oftentimes we're actually placing pressure on different areas of the bone to maintain the alignment that we need or prevent the two pieces from drifting to an extent where that angulation wouldn't be acceptable. And when we're placing casts around larger circumference limbs, Getting that mold with literally the palm of my hand, molding the cast and having that effect, the bone is more difficult. There's just more space. So sometimes those fractures drift. We just can't hold them in place as easily. So that's definitely something we look at when we check and say, okay, we'll put the cast on. Am I having that effect on the bone and with a larger circumference that's harder to do.

Kerry:

Okay. So yeah, obesity definitely makes it more complicated to even heal from them then and the type of fracture. Are there any other like signs or early signs of bone health issues that parents can look out for other than like repeated fractures?

Maureen:

You know, that's usually now there, there have been, I think two studies actually looked at growing pains, sort of these vague aches and pains of growing children and noted an improvement with vitamin D supplementation. And the peak improvement was at about three months after supplementing. And if the patients kept up with the supplementation, that that improvement, you know, was sustained. So the growing pains, you know, I feel like as an orthopedist, I should have a much better explanation of these aches and pains. And maybe it just is, you know, your bone is turning over, it's in a high state of turnover. But think vitamin D is definitely something that one can try to treat growing pains based on the literature we have. And I think that that really are the only signs in childhood. Again We're talking about something that may go clinically unnoticed, and then when we're 60, when we're 70, that's, you know, where the implication is. So. We need to start now.

Kerry:

Yeah. How big were those studies? Are they pretty substantial sizes or do You may not know that it's

Maureen:

yeah, no, there, so in terms of looking at pediatric fractures, there was a study of almost 700 pediatric patients that showed that children with low vitamin D worked at twofold higher risk of having a fracture when compared to norms. And then there was another study that showed that it could be up to six times higher likelihood of having a fracture and another study. And I think that was also in the hundreds of patients. The studies that had showed that children who are vitamin D deficient were at higher risk of needing surgery than patients who had similar fractures. but had normal levels of serum vitamin D.

Kerry:

So were they deficient with levels of under 30 or

Maureen:

Yes. So vitamin D deficient patients had up to a six time higher risk, six fold higher risk of having a fracture. We don't have those, you know, what happens when you don't supplement childhood and let's follow that particular individual out to adulthood. We don't have that yet, but you know, like I said, We do know when peak bone mass is, when we're in the process of building it, we know when we achieve it, we know how long that lasts, so if you just kind of extrapolate to, you know, we know we've got to have good bone health to get that peak bone mass and, you know, then that's it. So we don't want to start out essentially, you know, osteopenic or osteoporotic at 20.

Kerry:

Would you say that being an athlete in the younger years is something that helps prevent osteoporosis later in life, or do you have to have that continual exercise throughout life to help with that?

Maureen:

I think, you know, we know that being athletic will help build bone mass and we know that it helps sustain it because you, you're counseling your adult patients that they need to participate in these weight bearing activities and even strength training has been shown, you know, having muscle contractions across bone provides load. So it certainly helps in the sustaining bone mass. When we look at building, like many things, it is multifactorial. Right? So if you're participating athletic activities, you are providing those loads, you are probably, you know, also potentially not overweight. If you're participating in a lot of physical activity, perhaps the weight is easier to control. Athletes are often more focused on their diet, you know, the needs to execute. So there are probably a lot of factors that contribute to why kids who are participating in athletic activities. better set up to achieve that peak bone mass. But there's the flip side too. There's that, you know, if you are in a depleted state because your athletic activities are kind of over the level of what you're able to recharge there's that flip side. So I think that it is not, you know, I think that obtaining the best sort of bone health as a child, I think that is attainable. And I think that if we work with our pediatric colleagues and really talk about it, emphasize it. And share with parents, you know, this is the time if you, if we don't do it now, you don't get another chance to build peak bone mass. And I think that that's impactful because that's not something that we talk about. And that's not something most people know. So that's our job to. We've got to own the bone.

Kerry:

I love that. Yeah. It's definitely important. Do, do genetics play a role in like overall bone health? Mm hmm.

Maureen:

You know, they certainly do in adults, right? So we know that certain races are more prone to osteoporosis. You have your light skin, fair hair, Caucasians. And for children, I think that we're starting to understand what groups may be at higher risk for vitamin D deficiency, but We certainly have not evaluated genetics race, you know, sufficiently to understand, okay, well, you know, that same population who's at risk as an adult was at risk as a child.

Kerry:

hmm.

Maureen:

there are genetically inherited metabolic bone diseases that affect bone health. Those we understand. Better because we're looking at populations of patients that we know have a bone problem. But I think that we're not, pediatrics has not achieved the level of sophistication that the adult literature has.

Kerry:

Okay. Yeah. I mean, sometimes we see that the, my mom had osteoporosis whatnot, am I doomed to also get the kind of the same thing, but not as much with the kids.

Maureen:

Yeah. And I think that that's, you know, it may not play out That we can change what happens at sort of that adult end of the life cycle, because the development of osteoporosis, you said there are genetics involved, there's multifactorial contributions at that stage, but what we can change is where an individual starts at in adulthood. So where did they start at? Because if you're more at risk to have osteoporosis as an adult, and you're starting with not optimal peak bone mass, then we know that that sets an individual up for fragility fractures

Kerry:

Yeah, that makes sense. So getting to them earlier and get the message across, like you're, you're really, really trying to speak about, which is wonderful is so important. Do you have anything else to add on this topic? I was going to say on the bone,

Maureen:

and owning the bone

Kerry:

owning the bone.

Maureen:

No, I think it's, it is just have that conversation. And I think that one of the things that we have to do is make sure our caregivers understand that. what kind of foods have vitamin D and calcium and vitamin C in them and how much, you know, that's not necessarily something that we talk about. It's kind of a detailed conversation. So, you know, I'm talking to parents, we're talking to patients in their adolescence about making choices and why. But I think this, you know, this has to Reach a wider audience because a we'd like to see that the nutritional intake is optimal But we need to understand when it's not, we Have to supplement

Kerry:

Yeah. So basically if a kid doesn't drink milk or eat dairy, absolutely needs supplementation. Correct.

Maureen:

and if parents really want to know, you know this they want a level to understand that then I think that's reasonable, but you know, if you just look at what it takes to have those optimal levels, it's hard

Kerry:

It's also hard to give the baby the drops when you're exclusively breastfeeding. That's what I go back to it. I admit I didn't do it for my second and third kid. So I hope they don't get osteoporosis. Luckily they're boys. I hope that's good. Yeah. But my daughter got it. So we're good.

Maureen:

it's, it's all hard. I mean, it's hard to make sure your kids brush their teeth in the morning. You know, now I'm saying, Oh, you need to take this gummy and make sure that that happens. So I mean, it's not easy. And it has to sort of be come on part of the mechanism of daily life. So yes, where I'm adding something else on to their plate. But that's where I think if we, if we can just get started and figure out how to work it into life, then yes, it will be, I think we can do better.

Kerry:

Yeah. Well, thank you so much for educating me and everybody else. Cause I don't, these are several things that I was not aware of. So this is so, so important. So I'm happy to be able to, you know, share this on the podcast. Where can people find you if they want to reach out to you, if they have

Maureen:

So you can find me on the web. I'm at MaureenMaciel. com and I'm currently with Advent Health Medical Group. We have a pediatric specialty clinic. It's located on the site of the Advent Tampa Hospital. I I have a lot of information on my website and some of it is very specific to specific kinds of bone diseases. But, you know, this is the kind of thing that even myself, if I'm going to own the bone, I'm going to be putting up more information there so parents can find it there.

Kerry:

Awesome. Well, we'll definitely include that in the show notes and I just thank you so much for your time today and being on the podcast and I really appreciate it. And anything else you'd like to say?

Maureen:

No, thank you so much. It's been wonderful to talk to you about it.

Kerry:

Awesome. Well, tune in everybody next week. We'll hope we have a great episode and thank you so much for listening.

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Dr. Kerry Reller

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