Ewha Med J.  2023 Oct;46(4):e18. 10.12771/emj.2023.e18.

Diagnosis and Management of Osteoporosis in Children and Adolescents

  • 1Department of Pediatrics, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea


Recent advances in medicine have led to an increase in the number of children and adolescents treated for various chronic diseases and cancer. Increasingly sophisticated genetic analysis techniques have also clarified some genetic factors that contribute to bone fragility. Osteoporosis, characterized by reduced bone mass and skeletal fragility, can result from primary or secondary causes that originate in childhood and adolescence, which are critical periods for bone mineral acquisition. It is essential to identify children and adolescents at risk of fractures due to osteoporosis, and early intervention is crucial. Conservative management strategies, such as treating underlying diseases, replacing deficient hormones, providing nutritional support to meet calcium and vitamin D requirements, and encouraging regular physical activity, should be prioritized. Pharmacological treatment should be initiated in a timely manner following a comprehensive bone health examination. Intravenous pamidronate therapy has been safely and effectively administered to children and adolescents, although long-term follow-up is necessary. Further investigation is needed regarding bone fragility fractures of unknown etiology and the application of new medications for pediatric use.


Adolescent; Child; Osteoporosis; Pamidronate



1. Peck W. Consensus development conference: diagnosis, prophylaxis, and treatment of osteoporosis. Am J Med. 1993; 94((6)):646–650. DOI: 10.1016/0002-9343(93)90218-E. PMID: 8506892.
2. Heaney RP, Abrams S, Dawson-Hughes B, Looker A, Marcus R, Matkovic V, et al. Peak bone mass. Osteoporos Int. 2000; 11((12)):985–1009. DOI: 10.1007/s001980070020. PMID: 11256898.
3. Hedström EM, Svensson O, Bergström U, Michno P. Epidemiology of fractures in children and adolescents. Acta Orthop. 2010; 81((1)):148–153. DOI: 10.3109/17453671003628780. PMID: 20175744. PMCID: PMC2856220.
4. Lewiecki EM, Gordon CM, Baim S, Leonard MB, Bishop NJ, Bianchi ML, et al. International society for clinical densitometry 2007 adult and pediatric official positions. Bone. 2008; 43((6)):1115–1121. DOI: 10.1016/j.bone.2008.08.106. PMID: 18793764.
5. Bishop N, Arundel P, Clark E, Dimitri P, Farr J, Jones G, et al. Fracture prediction and the definition of osteoporosis in children and adolescents: the ISCD 2013 Pediatric Official Positions. J Clin Densitom. 2014; 17((2)):275–280. DOI: 10.1016/j.jocd.2014.01.004. PMID: 24631254.
6. Shuhart CR, Yeap SS, Anderson PA, Jankowski LG, Lewiecki EM, Morse LR, 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; 22((4)):453–471. DOI: 10.1016/j.jocd.2019.07.001. PMID: 31400968.
7. Ward LM, Weber DR, Munns CF, Högler W, Zemel BS. A contemporary view of the definition and diagnosis of osteoporosis in children and adolescents. J Clin Endocrinol Metab. 2020; 105((5)):e2088–e2097. DOI: 10.1210/clinem/dgz294. PMID: 31865390. PMCID: PMC7121121.
8. Kang MJ, Hong HS, Chung SJ, Lee YA, Shin CH, Yang SW. Body composition and bone density reference data for Korean children, adolescents, and young adults according to age and sex: results of the 2009–2010 Korean National Health and Nutrition Examination Survey (KNHANES). J Bone Miner Metab. 2016; 34((4)):429–439. DOI: 10.1007/s00774-015-0686-y. PMID: 26056024.
9. Lim JS, Hwang JS, Lee JA, Kim DH, Park KD, Cheon GJ, et al. Bone mineral density according to age, bone age, and pubertal stages in Korean children and adolescents. J Clin Densitom. 2010; 13((1)):68–76. DOI: 10.1016/j.jocd.2009.09.006. PMID: 19942470.
10. Yi KH, Hwang JS, Kim EY, Lee JA, Kim DH, Lim JS. Reference values for bone mineral density according to age with body size adjustment in Korean children and adolescents. J Bone Miner Metab. 2014; 32((3)):281–289. DOI: 10.1007/s00774-013-0488-z. PMID: 23832576.
11. Adams JE, Engelke K, Zemel BS, Ward KA. Quantitative computer tomography in children and adolescents: the 2013 ISCD Pediatric Official Positions. J Clin Densitom. 2014; 17((2)):258–274. DOI: 10.1016/j.jocd.2014.01.006. PMID: 24792821.
12. Ciancia S, Högler W, Sakkers RJB, Appelman-Dijkstra NM, Boot AM, Sas TCJ, et al. Osteoporosis in children and adolescents: how to treat and monitor? Eur J Pediatr. 2023; 182((2)):501–511. DOI: 10.1007/s00431-022-04743-x. PMID: 36472650.
13. Ward LM, Konji VN, Ma J. The management of osteoporosis in children. Osteoporos Int. 2016; 27((7)):2147–2179. DOI: 10.1007/s00198-016-3515-9. PMID: 27125514.
14. Galindo-Zavala R, Bou-Torrent R, Magallares-López B, Mir-Perelló C, Palmou-Fontana N, Sevilla-Pérez B, et al. Expert panel consensus recommendations for diagnosis and treatment of secondary osteoporosis in children. Pediatr Rheumatol. 2020; 18((1)):20. DOI: 10.1186/s12969-020-0411-9. PMID: 32093703. PMCID: PMC7041118.
15. Bardai G, Ward LM, Trejo P, Moffatt P, Glorieux FH, Rauch F. Molecular diagnosis in children with fractures but no extraskeletal signs of osteogenesis imperfecta. Osteoporos Int. 2017; 28((7)):2095–2101. DOI: 10.1007/s00198-017-4031-2. PMID: 28378289.
16. Marrani E, Giani T, Simonini G, Cimaz R. Pediatric osteoporosis: diagnosis and treatment considerations. Drugs. 2017; 77((6)):679–695. DOI: 10.1007/s40265-017-0715-3. PMID: 28271302.
17. Forlino A, Cabral WA, Barnes AM, Marini JC. New perspectives on osteogenesis imperfecta. Nat Rev Endocrinol. 2011; 7((9)):540–557. DOI: 10.1038/nrendo.2011.81. PMID: 21670757. PMCID: PMC3443407.
18. Forlino A, Marini JC. Osteogenesis imperfecta. Lancet. 2016; 387((10028)):1657–1671. DOI: 10.1016/S0140-6736(15)00728-X. PMID: 26542481.
19. Almeida M, Laurent MR, Dubois V, Claessens F, O’Brien CA, Bouillon R, et al. Estrogens and androgens in skeletal physiology and pathophysiology. Physiol Rev. 2017; 97((1)):135–187. DOI: 10.1152/physrev.00033.2015. PMID: 27807202. PMCID: PMC5539371.
20. Oh A, Lee Y, Yoo HW, Choi JH. Three pediatric patients with primary hyperparathyroidism caused by parathyroid adenoma. Ann Pediatr Endocrinol Metab. 2022; 27((2)):142–147. DOI: 10.6065/apem.2142006.003. PMID: 34015897. PMCID: PMC9260372.
21. Jin HY, Lee JA. Low bone mineral density in children and adolescents with cancer. Ann Pediatr Endocrinol Metab. 2020; 25((3)):137–144. DOI: 10.6065/apem.2040060.030. PMID: 33017885. PMCID: PMC7538298.
22. Compston J. Glucocorticoid-induced osteoporosis: an update. Endocrine. 2018; 61((1)):7–16. DOI: 10.1007/s12020-018-1588-2. PMID: 29691807. PMCID: PMC5997116.
23. Jang MJ, Shin C, Kim S, Lee JW, Chung NG, Cho B, et al. Factors affecting bone mineral density in children and adolescents with secondary osteoporosis. Ann Pediatr Endocrinol Metab. 2023; 28((1)):34–41. DOI: 10.6065/apem.2244026.013. PMID: 35798303. PMCID: PMC10073031.
24. Lee HS, Shim YS, Hwang JS. Treatment of congenital hypogonadotropic hypogonadism in male patients. Ann Pediatr Endocrinol Metab. 2022; 27((3)):176–182. DOI: 10.6065/apem.2244208.104. PMID: 36203268. PMCID: PMC9537667.
25. Cheng CH, Chen LR, Chen KH. Osteoporosis due to hormone imbalance: an overview of the effects of estrogen deficiency and glucocorticoid overuse on bone turnover. Int J Mol Sci. 2022; 23:1376. DOI: 10.3390/ijms23031376. PMID: 35163300. PMCID: PMC8836058.
26. Lee YA, Kwon A, Kim JH, Nam HK, Yoo JH, Lim JS, et al. Clinical practice guidelines for optimizing bone health in Korean children and adolescents. Ann Pediatr Endocrinol Metab. 2022; 27((1)):5–14. DOI: 10.6065/apem.2244060.030. PMID: 35368191. PMCID: PMC8984748.
27. Kalkwarf HJ, Khoury JC, Lanphear BP. Milk intake during childhood and adolescence, adult bone density, and osteoporotic fractures in US women. Am J Clin Nutr. 2003; 77((1)):257–265. DOI: 10.1093/ajcn/77.1.257. PMID: 12499350.
28. Winzenberg T, Powell S, Shaw KA, Jones G. Effects of vitamin D supplementation on bone density in healthy children: systematic review and meta-analysis. BMJ. 2011; 342:c7254. DOI: 10.1136/bmj.c7254. PMID: 21266418. PMCID: PMC3026600.
29. Pulungan A, Soesanti F, Tridjaja B, Batubara J. Vitamin D insufficiency and its contributing factors in primary school-aged children in Indonesia, a sun-rich country. Ann Pediatr Endocrinol Metab. 2021; 26((2)):92–98. DOI: 10.6065/apem.2040132.066. PMID: 33412749. PMCID: PMC8255856.
30. Reid IR. Vitamin D effect on bone mineral density and fractures. Endocrinol Metab Clin North Am. 2017; 46((4)):935–945. DOI: 10.1016/j.ecl.2017.07.005. PMID: 29080644.
31. Hind K, Burrows M. Weight-bearing exercise and bone mineral accrual in children and adolescents: a review of controlled trials. Bone. 2007; 40((1)):14–27. DOI: 10.1016/j.bone.2006.07.006. PMID: 16956802.
32. MacKelvie KJ, Khan KM, Petit MA, Janssen PA, McKay HA. A school-based exercise intervention elicits substantial bone health benefits: a 2-year randomized controlled trial in girls. Pediatrics. 2003; 112((6)):e447–e452. DOI: 10.1542/peds.112.6.e447. PMID: 14654643.
33. Soyka LA, Misra M, Frenchman A, Miller KK, Grinspoon S, Schoenfeld DA, et al. Abnormal bone mineral accrual in adolescent girls with anorexia nervosa. J Clin Endocrinol Metab. 2002; 87((9)):4177–4185. DOI: 10.1210/jc.2001-011889. PMID: 12213868.
34. Dwan K, Phillipi CA, Steiner RD, Basel D. Bisphosphonate therapy for osteogenesis imperfecta. Cochrane Database Syst Rev. 2016; 10((10)):CD005088. DOI: 10.1002/14651858.CD005088.pub4. PMID: 27760454.
35. Choi Y, Hwang S, Kim GH, Lee BH, Yoo HW, Choi JH. Genotype-phenotype correlations and long-term efficacy of pamidronate therapy in patients with osteogenesis imperfecta. Ann Pediatr Endocrinol Metab. 2022; 27((1)):22–29. DOI: 10.6065/apem.2142144.072. PMID: 35073670. PMCID: PMC8984751.
36. Yoon JH, Choi Y, Lee Y, Yoo HW, Choi JH. Efficacy and safety of intravenous pamidronate infusion for treating osteoporosis in children and adolescents. Ann Pediatr Endocrinol Metab. 2021; 26((2)):105–111. DOI: 10.6065/apem.2040150.075. PMID: 34218632. PMCID: PMC8255864.
37. Kim MJ, Kim SN, Lee IS, Chung S, Lee J, Yang Y, et al. Effects of bisphosphonates to treat osteoporosis in children with cerebral palsy: a meta-analysis. J Pediatr Endocrinol Metab. 2015; 28((11-12)):1343–1350. DOI: 10.1515/jpem-2014-0527.
38. Sbrocchi AM, Rauch F, Jacob P, McCormick A, McMillan HJ, Matzinger MA, et al. The use of intravenous bisphosphonate therapy to treat vertebral fractures due to osteoporosis among boys with Duchenne muscular dystrophy. Osteoporos Int. 2012; 23((11)):2703–2711. DOI: 10.1007/s00198-012-1911-3. PMID: 22297733.
39. Simm PJ, Biggin A, Zacharin MR, Rodda CP, Tham E, Siafarikas A, et al. Consensus guidelines on the use of bisphosphonate therapy in children and adolescents. J Paediatr Child Health. 2018; 54((3)):223–233. DOI: 10.1111/jpc.13768. PMID: 29504223.
40. Gün E, Kendirli T, Botan E, Uçar T, Aycan Z, Akar AR. Immobilization-induced symptomatic hypercalcemia treated with zoledronate in a child with a left ventricular assist device. Ann Pediatr Endocrinol Metab. 2021; 26((3)):205–209. DOI: 10.6065/apem.2040206.103. PMID: 34015907. PMCID: PMC8505043.
41. Ward LM, Choudhury A, Alos N, Cabral DA, Rodd C, Sbrocchi AM, et al. Zoledronic acid vs placebo in pediatric glucocorticoid-induced osteoporosis: a randomized, double-blind, phase 3 trial. J Clin Endocrinol Metab. 2021; 106((12)):e5222–e5235. DOI: 10.1210/clinem/dgab458. PMID: 34228102.
42. Bowden SA, Mahan JD. Zoledronic acid in pediatric metabolic bone disorders. Transl Pediatr. 2017; 6((4)):256–268. DOI: 10.21037/tp.2017.09.10. PMID: 29184807. PMCID: PMC5682380.
43. Lewiecki EM. Clinical use of denosumab for the treatment for postmenopausal osteoporosis. Curr Med Res Opin. 2010; 26((12)):2807–2812. DOI: 10.1185/03007995.2010.533651. PMID: 21050058.
44. Boyce AM. Denosumab: an emerging therapy in pediatric bone disorders. Curr Osteoporos Rep. 2017; 15((4)):283–292. DOI: 10.1007/s11914-017-0380-1. PMID: 28643220. PMCID: PMC5554707.
45. Majdoub F, Ferjani HL, Nessib DB, Kaffel D, Maatallah K, Hamdi W. Denosumab use in osteogenesis imperfecta: an update on therapeutic approaches. Ann Pediatr Endocrinol Metab. 2023; 28((2)):98–106. DOI: 10.6065/apem.2346058.029. PMID: 37401056. PMCID: PMC10329944.
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