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Low Bone Density and Osteoporosis in Children

Although most people associate osteoporosis − a condition characterized by low bone density and vulnerability to fractures − with women in mid-life and older, this condition also occurs with surprising frequency in children. In fact, parents of children who experience multiple fractures or sprains from seemingly mild injuries may want to consider having their child evaluated.

A woman and child drinking milk.

Causes of low bone density in children

“Pediatric orthopedists have developed a growing awareness of this condition, so we are seeing more cases than formerly,” says Shevaun Doyle, MD, Associate Attending Orthopedic Surgeon at Hospital for Special Surgery (HSS). “It may also be true that the actual number of otherwise healthy children with low bone density, is increasing for a variety of reasons.” Among these, she says, are:

  • less active lifestyle, particularly among urban children who live in northern climates
  • poor nutrition
  • decreased exposure to the sun − an important source of vitamin D, which helps calcium absorption in the digestive tract.

An increase in vitamin D deficiency may also be related to the growing rate of obesity in children. Because the vitamin is fat soluble, it is believed to be hoarded in the fat cells in of these young people, and therefore becomes unavailable systemically. In addition, research indicates that darker skinned patients tend to be at risk for vitamin D deficiency, because their higher level of melanin in the skin blocks absorption of sunlight, preventing the synthesis of vitamin D. However, many fair skinned patients are accustomed to applying sunscreen regularly, so they too are at risk of producing less vitamin D.

Other causes of low bone density include:

  • metabolic disorders, such as irregularities in estrogen, corticosteroid, thyroid and parathyroid hormones
  • gastrointestinal disorders that affect absorption of vitamin D
  • congenital disorders such as osteogenesis imperfecta
  • disorders that necessitate the chronic use of certain kinds of medications that interfere with bone production and resorption, such as glucocorticoids and anticonvulsants, stimulants used for ADHD, methotrexate, as well as replacement therapy for thyroid disorders
  • renal disease
  • neuromuscular disease
  • anorexia, and
  • prolonged immobilization


An initial assessment for low bone density will include laboratory measurements of vitamin D, serum calcium, alkaline phosphatase (an enzyme essential for bone mineralization), and thyroid and parathyroid hormones, both of which, if elevated, can affect calcium absorption.

Juvenile osteoporosis should be considered in children and adolescents with a clinically significant history of fractures and low bone mass. A clinically significant history would include use of any of the medications mentioned above, or having a bowel malabsorption disorder, reduced mobilization, and a history of more than one fracture or a low energy fracture.

To measure bone mineral density, the pediatric orthopedist uses dual X-ray absorptiometry (DXA or DEXA scan), in which two X-ray beams of differing energy are directed at the site being measured. In children, the spine is the preferred location thought to yield the most useful information. Once this image is obtained it is compared to an “ideal” standard, the mean BMD (bone mass density) value in healthy age peers.

However, this means of measuring bone mass in children is not regarded as completely reliable. Machines used to determine BMD in adults can significantly underestimate BMD in children, in whom bone is naturally less dense. In addition, ideally, each child’s BMD would be compared to that of healthy children not only of similar age, but also sex and level of skeletal maturity (summarized as a Z-score).

Additional information can be derived from less commonly utilized peripheral quantitative computed tomography (pQCT) which distinguishes between intramedullary (inner, spongy) bone and cortical bone (the tissue forming the surface of the bone), which is much denser. This measurement is taken at the wrist or tibia. This measurement is useful because the values obtained are independent of skeletal size and it only takes ten minutes to perform.

Conventional X-rays of a fracture are not reliable to yield information on the quality of the bone. Dr. Doyle says, however, that on occasion the white part of the image will appear “grainier” and less dense and may alert the orthopedist to the possibility that the child has osteopenia (thinning of the bone tissue that may be a precursor to osteoporosis).

Find a doctor at HSS who specializes in juvenile osteoporosis prevention.


Treatment for low bone density in children usually begins with a nutritional approach. While most families are aware that their children should be getting enough calcium and vitamin D in their diet, they may not know how much is needed and that the requirement for calcium changes with age. At age nine for example, the requirement increases by 300 milligrams – to 1300 milligrams a day, from that required at age eight, and continues at the new level until the child turns 19 and peak bone mass is achieved. The goal is to make sure the patient’s potential for laying down new bone is optimized during those years.

For the following chart, keep in mind that most foods represent calcium as a percentage of an adult daily value of 1000 milligrams. As a result, you can find out how much calcium is in a product by adding a zero to the end of the percentage. For example, 27%, as labeled on the package, would equal 270mg of calcium. While the daily recommended value is much less for children, you can still use this trick to calculate the volume of calcium in the product for the uses of the table below.

Daily calcium requirements

Birth - 6 months 6 - 12 months 1 - 3 years 4 - 8 years 9 - 18 years 19 - 50 years
210 mg 270 mg 500 mg 800 mg 1,300 mg 1,000 mg

Avoid more than 2500 mg of calcium daily.

In addition to milk, there are a variety of foods that contain calcium and can help children get sufficient levels of calcium in their daily diet. Some examples include:

Food Examples
Dairy Foods Milk, yogurt, cheese
Leafy green vegetables Broccoli, kale, spinach
Fruits Oranges
Beans and peas Tofu, peanuts, peas, black beans, baked beans
Fish Salmon, sardines
Miscellaneous Sesame seeds, blackstrap molasses, corn tortillas, almonds, brown sugar

Because calcium is best absorbed through the diet, Dr. Doyle encourages her patients to meet their daily requirement by making food choices they enjoy that are also high in calcium. However, if their lab tests continue to show insufficient levels, a calcium supplement may be necessary. “Some supplements don’t get absorbed as well as others, and patients metabolize various formulations differently, so it may be a matter of trial and error to find one that works,” says Dr. Doyle. A blood test that reveals a rising calcium level confirms the supplement’s efficacy.

It is rare that a child’s vitamin D level can be raised through food nutritional choices alone. Moreover, with more people avoiding sun exposure, vitamin D supplements are usually necessary.

The American Academy of Pediatrics recommends is that vitamin D be taken daily:

  • 400 international units from birth to one year old
  • 600 international units from one year old to 100 years old.

According to Dr. Doyle, many laboratories’ standard normal range of serum Vitamin D levels is a minimum level of 20 nanograms per deciliter of blood upon testing. However, she and her colleagues at HSS usually begin treating children with less than 30 nanograms per deciliter aggressively, as they believe this level to be insufficient.

Some children in whom an improved diet and supplements are not effective may be candidates for treatment with bisphosphonates, drugs that help prevent bone loss in adults with osteoporosis. “In children, these drugs have shown great promise in osteoporosis caused by congenital disorders, such as osteogenesis imperfecta, and may also be a good option for patients with metabolic disorders,” Dr. Doyle says. “However, their use in young patients is still experimental and must be followed very carefully.”

Looking to the future

Much of the current work on low bone density in young patients is focused on developing reliable diagnostic standards that could also lead to more precise treatment guidelines.

Researchers are also trying to determine whether there is any correspondence between specific bone density measurements obtained with DXA and risk of fracture. Such a correspondence has been established in adults. Some orthopedists are looking at ultrasound as a means of measuring bone density. While this technology offers the benefit of portability and lack of radiation exposure, the information that it provides is not yet considered to be sufficient to confirm a diagnosis of osteoporosis.

Find a doctor at HSS who specializes in juvenile osteoporosis prevention.

Summary by Nancy Novick


Shevaun Mackie Doyle, MD
Associate Attending Orthopedic Surgeon, Hospital for Special Surgery
Associate Professor of Orthopedic Surgery, Weill Cornell Medical College

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