AMERICAN ACADEMY OF PEDIATRICS

Committee on Nutrition

Calcium Requirements of Infants, Children, and Adolescents

ABSTRACT. This statement is intended to provide pe- There is evidence that childhood and adolescence
diatric caregivers with advice about the nutritional needs may represent an important period for achieving
of calcium of infants, children, and adolescents. It will long-lasting skeletal benefits from regular exercise.5
review the physiology of calcium metabolism and pro- For example, Welten et al6 showed in a large Dutch
vide a review of the data about the relationship between cohort of children that regular weight-bearing activ-
calcium intake and bone growth and metabolism. In
particular, it will focus on the large number of recent
ity had a greater influence on peak bone mass than
studies that have identified a relationship between child- dietary calcium.
hood calcium intake and bone mineralization and the
potential relationship of these data to fractures in ado- IDENTIFICATION OF MINERAL REQUIREMENTS
lescents and the development of osteoporosis in adult- DURING CHILDHOOD
hood. The specific needs of children and adolescents
Overview
with eating disorders are not considered.
It is recognized that a very low calcium intake can
contribute to the development of rickets in infants

A
pproximately 99% of total body calcium is
and children, especially those consuming very re-
found in the skeleton, with only small
strictive diets (eg, a macrobiotic diet).7 There are no
amounts found in the plasma and extravas-
reliable data on the lowest calcium intake needed to
cular fluid. Serum calcium exists in 3 fractions: ion-
prevent rickets or on the relationship among ethnic-
ized calcium (approximately 50%), protein-bound
ity, vitamin D status, physical activity, and diet in the
calcium (approximately 40%), and a small amount of
causation of rickets in children fed low-calcium di-
calcium that is complexed, primarily to citrate and
ets.8,9
phosphate ions. Serum calcium is maintained at a
Recent data support the possibility that a low bone
constant level by the actions of several hormones,
mass may be a contributing factor to some fractures
most notably parathyroid hormone and calcitonin.
in children. A relationship between the adolescent
Calcium absorption is by the passive vitamin D-
growth spurt and the risk of fractures has been
independent route or by the active vitamin D-depen-
shown.10,11 Goulding et al12 reported lower bone mass
dent route.1
at multiple sites in a group of 100 girls aged 3 to 15
Understanding calcium needs for different age
years with distal forearm fractures compared with
groups requires a consideration of the variable phys-
age-matched girls. For girls aged 11 to 15 years in the
iologic requirements for calcium during develop-
study by Goulding et al12 a lower calcium intake was
ment. For example, during the first month of life, the
reported for those with fractures compared with the
regulatory mechanisms that maintain serum calcium
control subjects. Wyshak and Frisch13 similarly re-
levels may not be entirely adequate in some other-
ported that high calcium intakes seem to exert a
wise healthy infants, and symptomatic hypocalcemia
protective effect against fractures in adolescent boys
can occur. However, in general, hypocalcemia is un-
and girls. They also reported a positive relationship
common in healthy children and adolescents, and
between cola beverage intake and bone fracture.
the primary need for dietary calcium is to enhance
Whether this is attributable to a potential effect of
bone mineral deposition.
excessive phosphorus in the colas impairing bone
Calcium requirements also are affected substan-
mineral status or to the lack of calcium intake related
tially by genetic variability and other dietary constit-
to the substitution of colas for dairy products is
uents. The interactions of these factors make identi-
uncertain. However, a direct harmful effect of a high
fication of a single unique number for the calcium
phosphorus intake affecting the bone mineral status
“requirement” for all children impossible.2– 4 How-
is unlikely in older children and adults.2 Further data
ever, several recent dietary guidelines have consid-
on the relationship between calcium intake and frac-
ered the data about calcium requirements and rec-
tures are needed before the magnitude of increased
ommended calcium intake levels that are calculated
fracture risk at different calcium intake levels can be
to benefit most children (Table 1).2,3
assessed. However, it is reasonable to conclude that
In addition to calcium intake, exercise is an impor-
low calcium intakes may be an important risk factor
tant aspect of achieving maximal peak bone mass.
for fractures in adolescents. This risk may be an issue
that adolescents can more readily relate to than a
The recommendations in this statement do not indicate an exclusive course long-term risk of osteoporosis.
of treatment or serve as a standard of medical care. Variations, taking into
account individual circumstances, may be appropriate.
Maintaining adequate calcium intake during child-
PEDIATRICS (ISSN 0031 4005). Copyright © 1999 by the American Acad- hood is necessary for the development of a maximal
emy of Pediatrics. peak bone mass. Increasing peak bone mass may be

1152 PEDIATRICS Vol. 104 No. 5 November 1999

TABLE 1. Dietary Calcium Intake (mg/d) Recommendations greatest benefit for promoting skeletal mineraliza-
in the United States2,3* tion and decreasing the ultimate risk of osteoporo-
Age 1997 NAS3 1994 NIH2 sis.18,19
0 to 6 mo† 210 400
The substantial limitations involved in obtaining
6 mo to 1 y† 270 600 and interpreting data about calcium balance are well
1 through 3 y 500 800 known. These include substantial technical problems
4 through 8 y 800 800 (4–5 y) with measuring calcium excretion and the difficulty
800–1200 (6–8 y) obtaining dietary intake control in children. Both of
9 through 18 y 1300 800–1200 (9–10 y)
1200–1500 (11–18 y) these are necessary for adequate balance studies.
These problems have been partly overcome by the
* Recommended intakes were provided in different forms by each development of stable isotopic methods to assess
source cited. The Food and Nutrition Board of the National
Academy of Sciences (NAS) released Recommended Dietary Al- calcium absorption and excretion.20 Nevertheless,
lowances until 1997. In 1997, it chose to use the term adequate intake more data are needed to establish the “optimal” level
for the recommendations for calcium intake but indicated that of calcium retention at different ages and the effects
these values were to be used as Recommended Dietary Allow- of development on calcium balance.6
ances. The NIH Consensus Conference did not specify a specific
term but indicated that these values were the “optimal” intake A major advance in the field during the last 25
levels. Dietary recommendations by the NAS are set to meet the years has been the development and improvement of
needs of 95% of the identified population of healthy subjects. The methods to measure total body and regional bone
NAS guideline should be the primary guideline utilized. mineral content by using various bone density tech-
† For infant values, the 1994 NIH Consensus Conference indicated niques. Currently, the technique used in many stud-
values for formula-fed infants, whereas the 1997 NAS report used
the infant fed human milk as the standard. ies is dual-energy radiograph absorptiometry. This
technique can rapidly measure the bone mineral con-
tent and bone mineral density of the entire skeleton
an important way to reduce the risk of osteoporosis or of regional sites with a virtually negligible level of
in later adulthood.2,14 This is a more difficult end radiation exposure. Furthermore, recent enhance-
point to identify than the development of rickets or ments in the precision of the technique have made it
fractures. Therefore, surrogate markers of mineral particularly suitable for assessing the effects of cal-
status are used to assess the consequences of differ- cium supplementation on bone mass in children of
ing levels of calcium intake. The primary surrogates all ages.21
used are optimization of calcium balance or achieve- Several groups have directly assessed the effects of
ment of greater bone mass in children with increased calcium supplementation on bone mass by using
calcium intake.3,14,15 dual-energy radiograph absorptiometry or similar
In children with chronic illnesses, fractures may techniques.22–25 These studies, however, also have
occur during childhood secondary to mineral defi- limitations. First, most supplementation studies
ciency associated with the disease process or the done in children involved relatively short-term sup-
effects of therapeutic interventions (ie, corticoste- plementation of 1 to 2 years. This period may be
roids) on calcium metabolism.16 However, minimal inadequate to fully assess the long-term benefits of
data generally are not available on the risks and calcium supplements on bone mineral density. The
benefits of increasing calcium intake in children with second is that these studies generally have been done
chronic illnesses above current dietary recommenda- using only 1 level of supplementation, which fre-
tions. Supplementation of vitamin D along with cal- quently has been given in pill form. This limited
cium may be necessary for a maximal response.17 dosing approach makes it difficult to identify an
optimal intake level or determine the relative bene-
Methods fits of dietary calcium versus supplements as a
Multiple approaches are used to assess mineral method of increasing calcium intake in children.
requirements in children. They include the follow- Several investigators have performed population-
ing: 1) measurement of calcium balance in persons based epidemiologic studies relating childhood or
with various levels of calcium intake; 2) measure- adult bone mass or fracture risk to calcium intake in
ment of bone mineral content, by dual-energy radio- childhood. Although many of these studies are lim-
graph absorptiometry or other techniques, in groups ited by their retrospective design, they have gener-
of children before and after calcium supplementa- ally shown a positive association between calcium
tion; and 3) epidemiologic studies relating bone mass intake in childhood and childhood and adult bone
or fracture risk in adults with childhood calcium mass. Not all studies have shown a benefit, however,
intake. and further data about this relationship are need-
The calcium balance technique consists of measur- ed.3,26 –28
ing the effects of any given calcium intake on the net
retention of calcium by the body. This approach has
RECOMMENDATIONS BY AGE GROUP
been the most commonly used to estimate require-
ment for minerals. Its usefulness is based on the Overview
rationale that virtually all retained calcium must be The specific requirements for calcium intake by
used, especially by children, to enhance bone miner- infants, children, and adolescents have been exten-
alization. It therefore is reasonable to expect that the sively reviewed by 2 panels in North America since
dietary intake that leads to the greatest level of cal- 1994.2,3 A summary of their recommendations is
cium retention is the intake that will lead to the shown in Table 1.

AMERICAN ACADEMY OF PEDIATRICS 1153

Infants from balance studies suggest that for most healthy
The optimal primary nutritional source during the children in this age range, the maximal net calcium
first year of life is human milk. No available evidence balance (plateau) is achieved with intakes between
shows that exceeding the amount of calcium retained 1200 and 1500 mg/d. That is, at intake levels above
by the exclusively breastfed term infant during the this, almost all of the additional calcium is excreted
first 6 months of life or the amount retained by the and not used. At intakes below that level, the skele-
human milk–fed infant supplemented with solid ton may not receive as much calcium as it can use,
foods during the second 6 months of life is beneficial and peak bone mass may not be achieved.2,3,9,15,18 –20
to achieving long-term increases in bone mineraliza- Virtually all the data used to establish this intake
tion. Available data demonstrate that the bioavail- level are from white children; minimal data are avail-
ability of calcium from human milk is greater than able for other ethnic groups. The exact level that is
that from infant formulas or cow’s milk, although best for a given person depends on other nutrients in
this comparison has not generally been made at com- the diet, genetics, exercise, and other factors.
parable intake concentrations, ie, such as found in Several controlled trials have found an increase in
human milk.29 Nevertheless, it has been deemed pru- the bone mineral content in children in this age
dent to increase the concentration of calcium in all group who have received calcium supplementa-
infant formulas relative to human milk to ensure at tion.22–25 However, the available data suggest that if
least comparable levels of calcium retention. Rela- calcium is supplemented only for relatively short
tively greater calcium concentrations are found in periods (ie, 1 to 2 years), there may not be long-term
specialized formulas, such as soy formulas and ca- benefits to establishing and maintaining a maximum
sein hydrolysates, to account for the potential lower peak bone mass.34,35 This emphasizes the importance
bioavailability of the calcium from these formulas of diet in achieving adequate calcium intake and in
relative to cow’s milk-based formula. Specific con- establishing dietary patterns consistent with a cal-
centration requirements cannot be set readily, but all cium intake near recommended levels throughout
formulas marketed should have demonstrated a net childhood and adolescence. Unfortunately, long-
calcium retention at least comparable to that of hu- term studies evaluating the consequences of main-
man milk. Research data are not available to justify taining currently recommended calcium intakes be-
the use of very high levels of calcium in infant for- ginning in childhood or early adolescence are not
mula for full-term infants. available. Most available epidemiologic data, re-
Premature infants have higher calcium require- cently reviewed by the National Academy of Sci-
ments than full-term infants while in the nursery. ences and the National Institutes of Health, support
These may be met by using human milk fortified the view that maintaining such a diet will increase
with additional minerals or with specially designed peak bone mass and lower the incidence of frac-
formulas for premature infants.30 After hospitaliza- tures.2,3
tion, there may be benefits to providing formula-fed Recent data obtained in African American adoles-
premature infants formulas with higher calcium con- cents suggest a link between lower diastolic blood
centrations than those of routine cow’s milk– based pressure and increased calcium intake. Further stud-
formulas.31 The optimal concentrations and length of ies are necessary to evaluate this relationship in chil-
time needed for such formulas are unknown. dren of multiple ethnicities and age groups.36

ACHIEVING RECOMMENDED INTAKES

Children
The gap between the recommended calcium in-
Few data are available about the calcium require- takes and the typical intakes of children, especially
ments of children before puberty. Calcium retention those 9 to 18 years of age, is substantial (Table 1).
is relatively low in toddlers and slowly increases as Mean intakes in this age group are between approx-
puberty approaches. Most available data indicate imately 700 and 1000 mg/d, with values at the higher
that calcium intake levels of about 800 mg/d are side of this range occurring in males.3 Preoccupation
associated with adequate bone mineral accumulation with being thin is common in this age group, espe-
in prepubertal children. The benefits of greater levels cially among females, as is the misconception that all
of intake in this age group have been studied inad- dairy foods are fattening. Many children and adoles-
equately.20,32 One study found a benefit of calcium cents are unaware that low-fat milk contains at least
supplements to children as young as 6 years of age.16 as much calcium as whole milk.
However, further supporting data are needed for this Knowledge of dietary calcium sources is a first
finding. Perhaps of most importance in this age step toward increasing the intake of calcium-rich
group is the development of eating patterns that will foods. Table 2 gives typical amounts of calcium for
be associated with adequate calcium intake later in some common food sources. The largest source of
life. dietary calcium for most persons is milk and other
dairy products.37 Other sources of calcium are, how-
Preadolescents and Adolescents ever, important, especially for achieving calcium in-
The majority of research in children about calcium takes of 1200 to 1500 mg/d. Most vegetables contain
requirements has been directed toward 9- to 18-year- calcium, although at low density. Therefore, rela-
olds. The efficiency of calcium absorption is in- tively large servings are needed to equal the total
creased during puberty, and the majority of bone intake achieved with typical servings of dairy prod-
formation occurs during this period.15,20,21,32,33 Data ucts. The bioavailability of calcium from vegetables

1154 CALCIUM REQUIREMENTS OF INFANTS, CHILDREN, AND ADOLESCENTS

TABLE 2. Approximate Calcium Contents of 1 Serving of Some Common Foods*
Food Serving Size Calcium Content
Milk† 1 cup 240 mL 300 mg
White beans 1⁄2 cup 110 g 113 mg
Broccoli cooked 1⁄2 cup 71 g 35 mg
Broccoli raw 1 cup 71 g 35 mg
Cheddar cheese 1.5 oz 42 g 300 mg
Low-fat yogurt 8 oz 240 g 300–415 mg
Spinach cooked‡ 1⁄2 cup 90 g 120 mg
Spinach raw‡ 11⁄2 cup 90 g 120 mg
Calcium-fortified orange juice 1 cup 240 mL 300 mg
Orange 1 medium 1 medium 50 mg
Sardines or salmon with bones 20 sardines 240 g 50 mg
Sweet potatoes 1⁄2 cup mashed 160 44
* Adapted from Raper et al,37 Weaver,38,39 and Weaver and Plawecki.40
† Low-fat milk has comparable or greater calcium levels than whole milk.
‡ The calcium from spinach is essentially nonbioavailable.

is generally high. An exception is spinach, which is rapid growth and bone mineralization associated
high in oxalate, making the calcium virtually nonbio- with pubertal development. The current dietary in-
available. Some high-phytate foods, such as whole take of calcium by children and adolescents is well
bran cereals, also may have poorly bioavailable cal- below the recommended optimal levels. The avail-
cium.38 – 40 able data support recent recommendations for cal-
Several products have been introduced that are cium intakes of 1200 to 1500 mg/d beginning during
fortified with calcium. These products, most notably the preteen years and continuing throughout adoles-
orange juice, are fortified to achieve a calcium con- cence as recommended by the National Institutes of
centration similar to that of milk. Limited studies of Health Consensus Conference2 and the National
the bioavailability of the calcium in these products Academy of Sciences.3 Currently, evidence is inade-
suggest that it is at least comparable to that of milk.41 quate to alter the dietary recommendations for chil-
It is likely that more such products will soon become dren with chronic illnesses or those taking medica-
available. Breakfast foods also are frequently forti- tions, such as corticosteroids, that alter bone
fied with minerals, including calcium. Calcium in- metabolism. However, an effort should be made to
takes on food labels are indicated as a percentage of achieve at least the recommended intake levels. The
the “daily value” in each serving. This daily value is provision of adequate vitamin D also may be impor-
currently set as 1000 mg/d. Therefore, it is important tant for children with chronic illnesses.
to instruct families about reading and interpreting
food labels. RECOMMENDATIONS
Several alternatives exist for children with lactose 1. Pediatricians should actively support the goal of
intolerance. Lactose intolerance is more common in achieving calcium intakes in children and adoles-
African American, Mexican Americans, and Asian cents comparable to those in recently recom-
Pacific Islanders than in whites.42 Many children mended guidelines.2,3 The prevention of future
with lactose intolerance can drink small amounts of osteoporosis, as well as the possibility of a de-
milk without discomfort. Other alternatives include creased risk of childhood and adolescent frac-
the use of other dairy products, such as solid cheeses tures, should be discussed as potential benefits to
and yogurt, that may be better tolerated than milk. achieving these goals. Currently, relatively few
Lactose-free and low-lactose milks are available. In- children and adolescents achieve dietary calcium
creasing the intake of nondairy products, such as intake goals.
vegetables, may be helpful, as may the use of calci- 2. To emphasize the importance of calcium nutrit-
um-supplemented foods. ure, pediatricians should consider including the
For children and adolescents who cannot or will following questions about dietary calcium intake.
not consume adequate amounts of calcium from any • What do you drink, either white or chocolate
dietary sources, the use of mineral supplements milk, with your meals?
should be considered. Although supplements vary in • Do you drink milk with meals, snacks, or cereal
their bioavailability, they may have bioavailability or any other time during the day?
comparable to or greater than that of dairy prod- • Do you eat cheese, yogurt, or other dairy prod-
ucts.43 Decisions about their use must be made on an ucts such as cottage cheese?
individual basis, keeping in mind the usual dietary • Do you drink calcium-fortified juices or eat any
habits of the person, any individual risk factors for calcium-fortified foods?
osteoporosis, and the likelihood that the use of the • Do you eat any of the following: broccoli, tofu,
supplement will be maintained. oranges, or legumes (dried beans and peas)?
• Do you take any mineral or vitamin supple-
CONCLUSION ments?
Recent studies and dietary recommendations have 3. For children and adolescents whose calcium in-
emphasized the importance of adequate calcium nu- take seems deficient, specific information about
triture in children, especially those undergoing the the sources of dietary calcium should be pro-

AMERICAN ACADEMY OF PEDIATRICS 1155

 vided. Adolescents may need to be reminded that 10. Bailey DA, Wedge JH, McCulloch RG, Martin AD, Bernhardson SC.
Epidemiology of fractures of the distal end of the radius in children as
low-fat dairy products, including skim milk and
associated with growth. J Bone Joint Surg Am. 1989;71:1225–1231
low-fat yogurts, are good sources of calcium that 11. Parfitt AM. The two faces of growth: benefits and risks to bone integrity.
are not high in fat. Osteoporos Int. 1994;4:382–398
12. Goulding A, Cannan R, Williams SM, Gold EJ, Taylor RW, Lewis-
Committee on Nutrition, 1998 –1999 Barned NJ. Bone mineral density in girls with forearm fractures. J Bone
Susan S. Baker, MD, PhD, Chairperson Miner Res. 1998;13:143–148
William J. Cochran, MD 13. Wyshak G, Frisch RE. Carbonated beverages, dietary calcium, the di-
Carlos A. Flores, MD etary calcium/phosphorus ratio, and bone fractures in girls and boys. J
Adolesc Health. 1994;15:210 –215
Michael K. Georgieff, MD
14. Miller GD, Weaver CM. Required versus optimal intakes: a look at
Marc S. Jacobson, MD calcium. J Nutr. 1994;124:1404S–1405S
Tom Jaksic, MD, PhD 15. Matkovic V, Ilich JZ. Calcium requirements for growth: are current
Nancy F. Krebs, MD recommendations adequate? Nutr Rev. 1993;51:171–180
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illnesses. In: Wastney ME, Siva Subramanian KN, eds. Kinetic Models of
Donna Blum-Kemelor, MS, RD
Trace Element and Mineral Metabolism During Development. Boca Raton,
US Department of Agriculture FL: CRC Press; 1995:159 –170
William Dietz, MD, PhD 17. Warady BD, Lindsley CB, Robinson FG, Lukert BP. Effects of nutritional
Centers for Disease Control and Prevention supplementation on bone mineral status of children with rheumatic
Gilman Grave, MD diseases receiving corticosteroid therapy. J Rheumatol. 1994;21:530 –535
National Institute of Child Health and Human 18. Jackman LA, Millane SS, Martin BR, et al. Calcium retention in relation
Development to calcium intake and postmenarcheal age in adolescent females. Am J
Suzanne S. Harris, PhD Clin Nutr. 1997;66:327–333
International Life Sciences Institute 19. Matkovic V, Heaney RP. Calcium balance during human growth: evi-
dence for threshold behavior. Am J Clin Nutr. 1992;55:992–996
Van S. Hubbard, MD, PhD
20. Abrams SA, Stuff JE. Calcium metabolism in girls: current dietary
National Institute of Diabetes and Digestive and intakes lead to low rates of calcium absorption and retention during
Kidney Diseases puberty. Am J Clin Nutr. 1994;60:739 –743
Ann Prendergast, RD, MPH 21. Ellis KJ, Abrams SA, Wong WW. Body composition in a young multi-
Maternal and Child Health Bureau ethnic female population. Am J Clin Nutr. 1997;65:724 –731
Alice E. Smith, MS, RD 22. Lloyd T, Andon MB, Rollings N, et al. Calcium supplementation and
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Elizabeth Yetley, PhD 23. Johnston CC Jr, Miller JZ, Slemenda CW, et al. Calcium supplementa-
Food and Drug Administration tion and increases in bone mineral density in children. N Engl J Med.
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Scott C. Denne, MD 25. Lee WT, Leung SS, Wang SH, et al. Double-blind, controlled calcium
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a low-calcium diet. Am J Clin Nutr. 1994;60:744 –750
Ronald M. Lauer, MD
26. Lee WT, Leung SF, Lui SS, Lau J. Relationship between long-term
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Consultant 5 years. Br J Nutr. 1993;70:235–248
Steven A. Abrams, MD 27. Matkovic V, Kostial K, Simonovic I, Buzina R, Brodarec A, Nordin BE.
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AMERICAN ACADEMY OF PEDIATRICS 1157