Outpatient Specialty Care and Primary Care Clinical Pathway for Children who may need a Dual Energy X-ray Absorptiometry (DXA) Bone Density Scan

Goals and Metrics
Patient Education
Provider Resources
Related Pathway
Patient Who May Benefit from a DXA Bone Scan
Diagnosed or Significant Risk
for Low Bone Mineral Density
At Risk for Bone Disease
Low Risk for Bone Disease
Clinical Recommendations by Body System/Clinical Disorder
  • Vitamin D deficiency
  • Obesity
  • Malnutrition not due to eating disorder or chronic disease
Obtain DXA scan
Consider DXA scan
DXA scan not indicated
Before ordering a DXA scan, use clinical judgment to
consider how the results will change patient care
Information About DXA Scans/Imaging Recommendations
DXA Scan Interpretation Based on Z-Score
Find results in EPIC within DXA Encounter
Preferred DXA Scan Sites
Patient Age Standard Scan Sites Alternative Scan Sites
3-5 yrs Lumbar
Whole body		  
5-18 yrs Lumbar
Whole body
  • Hip: Consider in post-pubertal adolescents when DXA monitoring into adulthood is expected
  • Forearm: Consider in pts ≥ 5 years when other sites cannot be assessed d/t contractures, etc.
  • Lateral distal femur: Consider in non-ambulatory patients 6-18 years of age
≥ 18 yrs Lumbar
Whole body
Hip		 Forearm
  • Recommended regions of interest (ROI) for clinical evaluation:
    • AP Lumbar Spine: “Total” (L1-L4)
    • Whole Body: “Subtotal” (total body less head)
    • Hip: “Total” (total hip), “Neck” (femoral neck)
    • Forearm: “1/3” (distal 1/3 radius)
Z-score ≤ -2
Low bone mineral density
Z-score > -2 up to +2
Bone density within expected reference range
  • Factors interfering with accurate interpretation:
    • Barium studies in the 7 days prior DXA scan
    • Contrast materials within the last 7 days
    • Calcium supplements within the last 24 hours
  • Other Ordering Considerations
  • Spinal disease or positional challenges
  • Hardware in scan sites
  • Ventilator dependence
Presence of
  • Primary bone disorder and/or
  • Clinically significant fractures
Absence of
  • Primary bone disorder and/or
  • Clinically significant fractures
Presence of
  • Primary bone disorder and/or
  • Known risk factors for impaired
    bone health
Absence of
  • Primary bone disorder and/or
  • Known risk factors for impaired bone health

Referral to bone health specialist

Treatment, DXA scan monitoring as indicated per specialist recommendations

Optimize treatment and management of underlying disease

Repeat DXA scan as clinically indicated and/or guidance by body system, DXA Scan Interpretation

Consider referral to bone health specialist

Reassess bone mineral density if clinical situation changes
Posted: September 2018
Revised: February 2021
Authors: M. Mascarenhas, MD; J. Webster, MD; D. Barsky, MD; F. Jannelli, RN; A. Calabria, MD; M. Downing, MHA;
D. Weber, MD; A. Puma, MSN