(69) The Multi-Disciplinary Team Approach to Screening for Bone Health in Children with Cystic Fibrosis (CF)

Background: It is important to identify and treat impaired bone mineral density (BMD) to prevent fractures and secondary complications. Individuals with CF are at increased risk for lower BMD due to medication related side effects, lower BMI, increased incidence of delayed puberty as well as the effect of abnormal CFTR. According to 2018 registry data, only 4% of patients over age 8 had completed a DEXA scan at the Yale Pediatric CF Center. Our aim was to improve assessment of bone health by using the multi-disciplinary team (MDT) to identify those at risk.

Methods: The MDT worked together to identify patients at our center who were at least 8yrs and should receive BMD screening based on the following risk factors: 1) Patients with < 90% ideal body weight – Our nurse coordinator queried from PortCF and our dietician screened as part of regular nutritional assessment. 2) Patients with FEV1< 50 % predicted - Our nurse coordinator queried from PortCF and our RT screened as part of regular assessment. 3) History of glucocorticoids use of > to 5mg/day for > 90 days per year or repeated antibiotic courses – Our pharmacists queried medication history. 4) History of fracture – Our PT added fracture screening in the regular musculoskeletal screen. 5) History of delayed puberty and patients over 18yrs– Identified during weekly clinic conference.

The initial roll out of our plan was delayed due to COVID. All members of the MDT were able to assist with explaining the process of DEXA scanning and importance. The clinic nurse coordinator and PT monitored for scan completion. They communicated to the team when results were available so that follow-up education and counseling could be provided. The date of completed scan and date of recommended follow-up were added to the weekly clinic log for tracking.

Results: Of the 57 patients in our pediatric clinic, 39 met criteria for BMD assessment. Our percentage of eligible patients completing screening rose from 4% in 2018, to 19.2% in 2019 and 33.3% in 2020 using a multi-disciplinary approach to patient identification and education. As of March 2022, 51% of eligible patients have now completed initial assessment. Of the 20 completed, 5 (20%) had results indicating low BMD for age. 3 received referrals for additional physical therapy due to overall low physical activity levels and moderate postural deviations. The remaining 2 were already involved in regular physical activity. Education on safe bone loading activity and protective education was provided. The team continues to provide dietary counseling and referrals to endocrine clinic as appropriate. 1 of the 5 patients with initial low BMD has completed a 2year follow-up scan and demonstrated significant improvement in BMD.

Conclusions: A multi-disciplinary approach to BMD screening provided to be very helpful in our clinic. Our percentage of eligible patients completing screening rose from 4% in 2018, to 19.2% in 2019 and 33.3% in 2020. We did encounter challenges in actually getting all appropriate patients to complete their scans, largely due to COVID. To date, 25% of those scanned were found to have low BMD for age. Standardizing multi-disciplinary education and counseling will be an important next step as will following the repeat scans of those whose initial scans were abnormal.

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