Paeds · endocrinology-diabetes-and-growth
Osteoporosis and fragility fractures in children
Also known as paediatric osteoporosis · childhood osteoporosis · low bone mass in children · glucocorticoid-induced osteoporosis in children · vertebral compression fracture in children
A fellowship approach to osteoporosis and fragility fractures in children: the ISCD framework that makes a low bone density Z-score only half the diagnosis, the primary-versus-secondary split where the steroid-treated and non-ambulant child dominate, the vertebral fracture that defines osteoporosis on its own, the growing skeleton's peak-bone-mass window, and the weight-based bisphosphonate pathway that now leads with intravenous zoledronic acid.
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- A child's low bone density Z-score alone is never osteoporosis — osteoporosis in a child requires the low bone mass plus a clinically significant fragility fracture, or a vertebral compression fracture regardless of density, so never use the adult T-score logic or label a thin child osteoporotic from a number
- A vertebral compression fracture in a child defines osteoporosis on its own, even when the DXA is normal — the steroid-treated child with back pain or height loss needs a lateral thoracolumbar spine, not reassurance
- The steroid-treated child is at highest vertebral-fracture risk in the first one to three years after glucocorticoids start, not after years of accumulated dose — screen the spine early, not late
- Before any bisphosphonate, the child must be calcium and vitamin D replete, because the first zoledronic acid infusion predictably lowers calcium and an unprepared child develops symptomatic hypocalcaemia
- A low alkaline phosphatase in a fracturing child is hypophosphatasia, not osteoporosis — bisphosphonates worsen it, so read the alkaline phosphatase before prescribing
- Unexplained fractures in a pre-mobile infant must always raise non-accidental injury and osteogenesis imperfecta together; the biochemistry, the radiographic pattern, and the safeguarding assessment separate them
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- Endocrinology and diabetes
- General and Community Paediatrics
- Growth and Development
- Endocrinology - recognise, investigate and manage metabolic bone disease, low bone mass and osteoporosis in children including glucocorticoid-induced and neuromuscular bone disease
- General and community paediatrics - recognise bone health in chronic illness, disability and the steroid-treated child
- Renewed curriculum for first-year trainees from 2027 - Learning goal 6: Clinical management - essential general paediatrics
- Endocrinology 10-12
- Metabolic bone disease 10-12
- Clinical Applications
- Long Cases
- Short Cases
- 5. Endocrinology and growth - disorders of bone mineralisation, bone density and fragility
- 11. Care of the chronic, complex and palliative child including disability
- 4. Professional skills and knowledge: Patient management
- Foundation of Practice (FOP)
- Theory and Science (TAS)
- Applied Knowledge in Practice (AKP)
- Clinical
- History
- Communication
- Video
- General Pediatrics Content Outline - D22 Endocrinology (4%)
- General Pediatrics Content Outline - Universal Task 4: Management and Treatment
- General Pediatrics Content Outline - Chronic and complex conditions
- Patient Care 4: Clinical Reasoning
- Patient Care 5: Patient Management
- Medical Knowledge 1: Congenital anomalies and genetics
- Systems-Based Practice 1: Patient Safety
- Medical Expert
- Pediatrics: Foundations EPA #8 - Communicating assessment findings and management plans to patients and/or families
- Pediatrics: Endocrinology and nutrition applied domain
Picture the child who walks in. A nine-year-old boy with Duchenne muscular dystrophy, on daily prednisolone for two years, complains of back pain and has lost two centimetres of height; the lateral spine shows a wedge fracture at T12. Or a fourteen-year-old girl with Crohn disease on a glucocorticoid wean who fractures her forearm turning over in bed. Or a previously well six-year-old whose recurrent long-bone fractures turn out to be osteogenesis imperfecta rather than misfortune. The fellowship task in each is to read the density and the fracture history together, to image the spine, and to treat the cause and the bone rather than the number alone. [7] [10]
Hold three things in mind: the Z-score (not the T-score, ever, in a child), the Fragility-fracture history, and the Vertebral-fracture search. A Z-score of minus two or lower gives you low bone mass, but it takes a fragility fracture or a vertebral compression fracture to make osteoporosis. A collapsed vertebra is osteoporosis at any density. Reach for the lateral thoracolumbar spine before you reach for a label. [1] [2]
Overview & Definition
Osteoporosis in a child is a disorder of bone strength in which the skeleton is fragile enough to fracture under forces that a healthy bone would withstand. Bone strength has two parts: how much mineral is packed into the bone, and how well that bone is built — its geometry, its microarchitecture, and the material quality of its matrix. A dual-energy X-ray absorptiometry scan estimates only the first part, which is why the density number alone never makes the diagnosis. The fracture is the proof that the strength has failed. [1] [6]
The definition that fellowship candidates must hold is the International Society for Clinical Densitometry framework, set at the 2013 Pediatric Position Development Conference and carried forward in 2019. A child or adolescent has osteoporosis when they have low bone mass — a BMD Z-score of minus two or lower, adjusted for age and sex — together with a clinically significant fracture history. That fracture history is one or more vertebral compression fractures, or two or more long-bone fractures before age ten, or three or more before age nineteen. Critically, a vertebral compression fracture alone satisfies the definition regardless of the bone density, because the vertebra has demonstrated fragility. [1] [2]
The distinction from adult medicine is the trap that costs marks. Adults use the T-score, which compares bone to a healthy young adult reference, and a T-score of minus two point five or lower is osteoporosis by itself. Children use the Z-score, which compares bone to age- and sex-matched peers, and a low Z-score is labelled low bone mass for age — never osteoporosis — until a fragility fracture is documented. A child is growing and accruing bone, and a low density in a growing skeleton is a risk state, not a disease. [1] [5]
References14ShowHide
- [1]Bishop N, Arundel P, Clark E, et al. Fracture prediction and the definition of osteoporosis in children and adolescents: the ISCD 2013 Pediatric Official Positions. J Clin Densitom, 2014.PMID 24631254
- [2]Weber DR, Boyce A, Gordon C, et al. The Utility of DXA Assessment at the Forearm, Proximal Femur, and Lateral Distal Femur, and Vertebral Fracture Assessment in the Pediatric Population: 2019 ISCD Official Position. J Clin Densitom, 2019.PMID 31421951
- [3]Shuhart CR, Yeap SS, Anderson PA, et al. Executive Summary of the 2019 ISCD Position Development Conference on Monitoring Treatment, DXA Cross-calibration and Least Significant Change, Spinal Cord Injury, Peri-prosthetic and Orthopedic Bone Health, Transgender Medicine, and Pediatrics. J Clin Densitom, 2019.PMID 31400968
- [4]Ciancia S, Högler W, Sakkers RJB, et al. Osteoporosis in children and adolescents: how to treat and monitor? Eur J Pediatr, 2023.PMID 36472650
- [5]Cannalire G, Biasucci G, Bertolini L, et al. Osteoporosis and Bone Fragility in Children: Diagnostic and Treatment Strategies. J Clin Med, 2024.PMID 39201093
- [6]Formosa MM, Christou MA, Mäkitie O Bone fragility and osteoporosis in children and young adults. J Endocrinol Invest, 2024.PMID 37668887
- [7]Ward LM, Bakhamis SA, Koujok K Approach to the Pediatric Patient With Glucocorticoid-Induced Osteoporosis. J Clin Endocrinol Metab, 2025.PMID 39126675
- [8]LeBlanc CM, Ma J, Taljaard M, et al. Incident Vertebral Fractures and Risk Factors in the First Three Years Following Glucocorticoid Initiation Among Pediatric Patients With Rheumatic Disorders. J Bone Miner Res, 2015.PMID 25801315
- [9]Humphrey MB, Russell L, Danila MI, et al. 2022 American College of Rheumatology Guideline for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis. Arthritis Rheumatol, 2023.PMID 37845798
- [10]Marini JC, Forlino A, Bächinger HP, et al. Osteogenesis imperfecta. Nat Rev Dis Primers, 2017.PMID 28820180
- [11]Ward LM, Choudhury A, Alos N, et al. Zoledronic Acid vs Placebo in Pediatric Glucocorticoid-induced Osteoporosis: A Randomized, Double-blind, Phase 3 Trial. J Clin Endocrinol Metab, 2021.PMID 34228102
- [12]Simm PJ, Biggin A, Zacharin MR, et al. Consensus guidelines on the use of bisphosphonate therapy in children and adolescents. J Paediatr Child Health, 2018.PMID 29504223
- [13]Ward L, Tricco AC, Phuong P, et al. Bisphosphonate therapy for children and adolescents with secondary osteoporosis. Cochrane Database Syst Rev, 2007.PMID 17943849
- [14]Ward LM, Weber DR, Wong SC, et al. A Parent Project Muscular Dystrophy-sponsored International Workshop Report on Endocrine and Bone Issues in Patients with Duchenne Muscular Dystrophy: An Ever-changing Landscape. J Neuromuscul Dis, 2025.PMID 39973454