Rethinking race-based interpretation in pediatric densitometry: a scoping review

As pediatric populations in the United States (US) become increasingly diverse, current practices for interpreting bone density using DXA in children warrant reevaluation. The International Society for Clinical Densitometry currently recommends adjusting pediatric bone density Z-scores by race, sex, and age. However, race-based adjustments risk reinforcing disparities and perpetuating systemic inequities in pediatric bone health assessment. We conducted a scoping review of studies examining racial and ethnic differences in BMD among healthy US children, identifying 3960 records across 4 databases, of which 54 met inclusion criteria. Across these studies, reporting of race and ethnicity was inconsistent: although nearly all relied on self- or parent-report, none provided explicit definitions, and only 13% confirmed concordance across grandparents. Fifty percent of studies reported statistically significant racial differences in BMD, yet most did so without comprehensive covariate adjustment. By contrast, studies that accounted for height, lean mass, and pubertal status frequently found that differences attenuated or disappeared. These findings underscore the need to critically reconsider race-based adjustments in pediatric DXA interpretation. Developing and validating race-neutral reference standards, with attention to structural determinants and biologically relevant measures, such as stature, body composition, and pubertal timing, is essential for achieving a more equitable and clinically meaningful assessment of pediatric bone health.