This is the current release of the guideline.

It updates a previously published guideline summary: American Academy of Pediatrics. Committee on Nutrition. Calcium requirements of infants, children, and adolescents. Pediatrics. 1999 Nov;104(5 Pt 1):1152-7.

All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

• Bone health
• Osteoporosis and bone fractures

Management
Prevention

Family Practice
Nutrition
Pediatrics
Preventive Medicine

Advanced Practice Nurses
Dietitians
Nurses
Physician Assistants
Physicians

To present recommendations for optimizing bone health and calcium intake in infants, children, and adolescents in the United States

Infants, children, and adolescents in the United States

1. Periodically assessing calcium intake and risk factors for suboptimal bone health in the office setting, including
   • Asking questions regarding dietary practices
   • Providing information regarding approximate calcium contents in one serving of some common foods
   • Assessing family history of osteoporosis
2. Encouraging weight-bearing exercise
3. Consultation with registered dietitian if necessary
4. Consideration of alternative sources of calcium if needed
5. Ensuring adequate intake of vitamin D

• Calcium intake
• Risk of fractures
• Calcium balance
• Bone mass and bone mineral content

Searches of Electronic Databases

Not stated

Not stated

Expert Consensus (Committee)

Not applicable

Review

Not stated

Not stated

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

Peer Review

Not stated

Recommendations for Adequate Dietary Calcium Intake in the United States (Institute of Medicine, Food and Nutritional Board, 1997)

The Food and Nutrition Board of the National Academy of Sciences (NAS) released recommended dietary allowances for calcium in 1997. The term "adequate intake" was applied to calcium recommendations. Application of the adequate intake is similar to that of the recommended dietary allowance. The American Academy of Pediatrics recommends that the NAS guidelines should be the primary guidelines used.

^a The 1997 NAS report used data based on younger infants (0-6 months) who are fed human milk exclusively.

^b The 1997 NAS report was based on the assumption that older infants (6 months to 1 year) would be consuming a diet of human milk and solid foods, which would be similar to that of formulated infants at this age.

Key Points

1. Pediatricians can actively promote bone health and support the goal of achieving adequate calcium intakes by children and adolescents by promoting the recommended adequate intakes of the Food and Nutrition Board of the National Academy of Sciences (NAS) (Institute of Medicine, Food and Nutritional Board, 1997) (see table above). The prevention of future osteoporosis and the possibility of a decreased risk of fractures in childhood and adolescence should be discussed with patients and families as potential benefits for achieving these goals.
2. Physical activity, primarily weight-bearing exercise, is encouraged as part of an overall healthy bone program.
3. Currently, the average dietary intake of calcium by children and adolescents (Fig 1 in the original guideline document) is well below the recommended levels of adequate intake (see table above). Information regarding calcium content of various foods should be given to patients and families for whom calcium intake seems inadequate. A registered dietitian may be consulted for a more thorough assessment of diet and to make the necessary recommendations to improve calcium.
4. Inadequate calcium intake by the child or adolescent is a family issue. Adequate intake of dietary calcium should be encouraged for all family members (see table above).
5. In the office setting, calcium intake can be assessed periodically with a simple questionnaire. Suggested ages for screening are 2 to 3 years of age, after the transition from human milk or formula; 8 to 9 years of age during preadolescence; and again during adolescence, when the peak rate of bone mass accretion occurs. Targeted questions are suggested (see Table 3 in the original guideline document) to assess calcium intake, general diet, and lifestyle practices relevant to bone health.
6. The most common sources of calcium in the Western diet are milk and other dairy products. Whole milk is not recommended until after 12 months of age, although yogurt and cheese can be introduced after 6 months. Low-fat dairy products including skim milk and low-fat yogurts are good sources of calcium. Nondairy calcium-rich foods are the next preferred source, although the calcium in soy products has low bioavailability. Calcium supplements are another alternative source, but these products do not offer the benefits of other associated nutrients, and compliance may be a problem. Most people can achieve the recommended dietary intake of calcium by eating 3 age-appropriate servings of dairy products per day (4 servings per day for adolescents) or the equivalent.
7. The diet of all infants (including those who are breastfeeding [Gartner et al., 2005]), children, and adolescents should include the recommended adequate intakes of vitamin D (200 IU [5.0 micrograms] or 500 mL of vitamin D-fortified formula or milk per day [Institute of Medicine, Food and Nutritional Board, 1997; Gartner & Greer, 2003]) as well as fruits and vegetables that are sources of potassium and bicarbonate, which may improve calcium retention.

None provided

The type of evidence supporting the recommendations is not specifically stated.

Maintaining adequate calcium intake during childhood and adolescence is necessary for the development of peak bone mass, which may be important in reducing the risk of fractures and osteoporosis later in life. Optimal calcium intake is especially relevant during adolescence, when most bone mineral accretion occurs.

Although data on calcium toxicity in children 1 through 18 years of age are limited, high calcium intake in small children may increase the risk of zinc and iron deficiency attributable to the adverse affect of calcium on the absorption of these minerals.

The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

An implementation strategy was not provided.

Staying Healthy

Effectiveness
Patient-centeredness

Not applicable: The guideline was not adapted from another source.

1999 (revised 2006 Feb)

American Academy of Pediatrics - Medical Specialty Society

American Academy of Pediatrics

Committee on Nutrition

Committee on Nutrition, 2003-2004: Nancy F. Krebs, MD, Chairperson; Robert D. Baker, Jr, MD, PhD; Jatinder J.S. Bhatia, MD; Frank R. Greer, MD; Melvin B. Heyman, MD; Fima Lifshitz, MD

Liaisons: Donna Blum-Kemelor, MS, RD, US Department of Agriculture; Margaret P. Boland, MD, Canadian Paediatric Society; William Dietz, MD, PhD, Centers for Disease Control and Prevention; Capt. Van Saxton Hubbard, MD, PhD, National Institutes of Health; Susan J. Walker, MD, US Food and Drug Administration

Staff: Pamela T. Kanda, MPH

Not stated

This is the current release of the guideline.

It updates a previously published guideline summary: American Academy of Pediatrics. Committee on Nutrition. Calcium requirements of infants, children, and adolescents. Pediatrics. 1999 Nov;104(5 Pt 1):1152-7.

All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

None available

This NGC summary was completed by ECRI on April 3, 2006. The information was verified by the guideline developer on April 11, 2006.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions. Please contact the Permissions Editor, American Academy of Pediatrics (AAP), 141 Northwest Point Blvd, Elk Grove Village, IL 60007.