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History

Patients with low bone mineral density for age may be asymptomatic or may present with bone pain. Many have had fractures or imaging studies (usually radiographs or dual-energy x-ray absorptiometry [DXA] studies) suggestive of demineralization or failure to accrue normal bone. Some have a history that suggests an underlying genetic or other condition. Peripubertal children with idiopathic juvenile osteoporosis often experience a gradual onset of pain, primarily in the lower body (eg, hips, ankles, knees, feet), manifested by discomfort when walking.

Fractures are common in healthy youth. By 16 years of age, nearly one-half of boys and one-third of girls have sustained a fracture. The clinical challenge remains in identifying those children with skeletal pathology associated with their fracture. The first step in ascertaining this is questioning about the mechanism and site of the fracture. In pediatrics, hip, femur, and vertebral fractures are rare and fractures that take place after minimal trauma may be concerning. Taken together, a history of axial skeletal fractures or multiple fractures from low biomechanical force may be indicators of skeletal fragility and should raise concern for osteoporosis.^[24]

Physical Examination

Often the results of a general examination of a child with osteoporosis can be normal. Some children have joint hypermobility or hypomobility. Children with spine disease may present with spinal deformities (eg, kyphosis, kyphoscoliosis), with short stature and/or a shortened upper to lower segment ratio. Pectus deformities (both carinatum and excavatum) can also be present. More severe forms of metabolic bone disease can present with long bone deformities. Limping or splinting due to pain may also be observed.

In genetic forms of primary osteoporosis, such as osteogenesis imperfecta, additional examination findings can include characteristic facial features, blue sclerae, dentinogenesis imperfecta, and hypermobility.

Differential Diagnoses

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Media Gallery

Prediction of bone loss with biochemical bone markers. Adapted from Ross PD, Knowlton W. Rapid bone loss is associated with increased levels of biochemical markers. (DPD stands for deoxypyridinoline.) J Bone Miner Res 1998 Feb; 13(2): 297-302.

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Table 1. Conditions Associated with Reduced Bone Mass in Children and Adolescents

Genetic conditions

Osteogenesis imperfecta

Idiopathic juvenile osteoporosis

Turner syndrome

Chronic illness

Cystic fibrosis

Connective tissue disorders (lupus, juvenile idiopathic arthritis, juvenile dermatomyositis)

Inflammatory bowel disease, celiac disease

Chronic renal failure

Childhood cancer

Cerebral palsy

Chronic immobilization

Eating disorders, including anorexia nervosa, bulimia nervosa, eating disorders not otherwise specified, and the female athlete triad

Endocrine disorders

Cushing syndrome

Hypogonadism

Hyperthyroidism

Hyperparathyroidism

Growth hormone deficiency

Diabetes mellitus

Medications

Glucocorticoids

Anticonvulsants

Chemotherapy

Leuprolide acetate

Proton pump inhibitors

Selective serotonin reuptake inhibitors

Depot medroxyprogesterone acetate (DMPA)

Table 2. Calcium and Vitamin D Dietary Reference Intakes ^[11]

Age	Calcium		Vitamin D
Age	RDA (mg/d) (Intake That Meets Needs of ≥97.5% of Population)	UL (mg/d)^a	RDA (IU/d) (Intake That Meets Needs of ≥97.5% of Population)	UL (IU/d)^a
Infants
0-6 mo	200^b	1000	400^b	1000
6-12 mo	260^b	1500	400^b	1500
1-3 y	700	2500	600	2500
4-8 y	1000	2500	600	3000
9-13 y	1300	3000	600	4000
14-18 y	1300	3000	600	4000

Table 3. Dietary Sources of Calcium

Food	Serving Size	Calories per Portion	Calcium Content (mg)
Dairy foods
Milk
Whole milk	8 oz	149	276
Reduced-fat milk (2%)	8 oz	122	293
Low-fat milk (1%)	8 oz	102	305
Skim milk (nonfat)	8 oz	83	299
Reduced-fat chocolate milk (2%)	8 oz	190	275
Low-fat chocolate milk (1%)	8 oz	158	290
Yogurt
Plain yogurt, low-fat	8 oz	143	415
Fruit yogurt, low-fat	8 oz	232	345
Plain yogurt, nonfat	8 oz	127	452
Cheese
Romano cheese	1.5 oz	165	452
Swiss cheese	1.5 oz	162	336
Pasteurized processed American cheese	2 oz	187	323
Mozzarella cheese, part skim	1.5 oz	128	311
Cheddar cheese	1.5 oz	171	307
Muenster cheese	1.5 oz	156	305
Nondairy foods
Salmon	3 oz	76	32
Sardines, canned	3 oz	177	325
White beans, cooked	1 cup	307	191
Broccoli, cooked	1 cup	44	72
Broccoli, raw	1 cup	25	42
Collards, cooked	1 cup	49	226
Spinach, cooked	1 cup	41	249
Spinach, raw	1 cup	7	30
Baked beans, canned	1 cup	680	120
Tomatoes, canned	1 cup	71	84
Calcium-fortified food
Orange juice	8 oz	117	500
Breakfast cereals	1 cup	100-210	250-1000
Tofu, made with calcium	0.5 cup	94	434
Soy milk, calcium fortified^a	8 oz	104	299

Table 4. Sources of Vitamin D

Food	Serving Size	Vitamin D Content^a (IU)
Natural sources
Salmon
Fresh wild	3.5 oz	600-1000
Fresh farmed	3.5 oz	100-250
Sardines, canned	3.5 oz	300
Mackerel, canned	3.5 oz	250
Tuna, canned	3.5 oz	236
Shiitake mushroom
Fresh	3.5 oz	100
Canned	3.5 oz	1600
Egg, hard-boiled	3.5 oz	20
Vitamin D-fortified foods
Infant formula	1 cup (8 oz)	100
Milk	1 cup (8 oz)	100
Orange juice^b	1 cup (8 oz)	100
Yogurts^b	1 cup (8 oz)	100
Cheeses^b	3 oz	100
Breakfast cereals^b	1 serving	40-100
Pharmaceutical sources in the United States
Vitamin D₂ (ergocalciferol)	1 capsule	50000
Drisdol (vitamin D₂) liquid	1 cc	8000
Supplemental sources
Multivitamin		400, 500, 1000
Vitamin D₃		400, 800, 1000, 2000, 5000, 10,000, 50,000

Table 5. Treatment of Vitamin D Deficiency

Age	Preparation and Dose^a
Infants, 0-12 mo	Vitamin D₂ or D₃ 50,000 IU weekly for 6 wk	or	Vitamin D₂ or D₃ 2000 IU daily for 6 wk
Infants, 0-12 mo	Followed by a maintenance dose of 400-1000 IU daily		Followed by a maintenance dose of 400-1000 IU daily
Children and adolescents, 1-18y	Vitamin D₂ or D₃ 50 000 IU weekly for 6-8 wk	or	Vitamin D₂ or D₃ 2000 IU daily for 6-8 wk
Children and adolescents, 1-18y	Followed by a maintenance dose of 600-1000 IU daily		Followed by a maintenance dose of 600-1000 IU daily

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Author

Manasa Mantravadi, MD, MS Assistant Research Professor in Endocrinology/Diabetology, Department of Pediatrics, Indiana University School of Medicine

Manasa Mantravadi, MD, MS is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Coauthor(s)

Stephanie E Woerner, RN, MSN, FNP-C, CDE Family Nurse Practitioner, Pediatric Endocrinology and Diabetology, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine; Family Nurse Practitioner, MinuteClinic, Inc

Disclosure: Nothing to disclose.

Linda A DiMeglio, MD, MPH Associate Professor of Pediatrics, Section of Pediatric Endocrinology and Diabetology, Department of Pediatrics, Indiana University School of Medicine; Director, Type 1 Diabetes Research Team, Riley Hospital for Children at Indiana University Health

Linda A DiMeglio, MD, MPH is a member of the following medical societies: American Academy of Pediatrics, American Diabetes Association, American Society for Bone and Mineral Research, Endocrine Society, Midwest Pediatric Endocrine Society, Pediatric Endocrine Society, Society for Pediatric Research

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Janssen<br/>Received research grant from: Alexion.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Jatinder Bhatia, MBBS, FAAP Professor of Pediatrics, Medical College of Georgia, Georgia Regents University; Chief, Division of Neonatology, Director, Fellowship Program in Neonatal-Perinatal Medicine, Director, Transport/ECMO/Nutrition, Vice Chair, Clinical Research, Department of Pediatrics, Children's Hospital of Georgia

Jatinder Bhatia, MBBS, FAAP is a member of the following medical societies: Academy of Nutrition and Dietetics, American Academy of Pediatrics, American Association for the Advancement of Science, American Pediatric Society, American Society for Nutrition, American Society for Parenteral and Enteral Nutrition, Society for Pediatric Research, Southern Society for Pediatric Research

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Nestle<br/>Serve(d) as a speaker or a member of a speakers bureau for: Nestle<br/>Received income in an amount equal to or greater than $250 from: Nestle.