Bone health is now recognized as an important facet of child health with sufficient evidence to support standardized approaches to diagnosis, monitoring, treatment, and prevention. Current management strategies are based on monitoring at-risk children to identify and then treat earlier rather than later signs of osteoporosis in those with limited potential for spontaneous recovery. Research studies addressing prevention of the first-ever fracture are still needed for children who have both a high likelihood of developing fractures and less potential for recovery.This chapter focuses on the evidence that shapes the current approach to diagnosis, monitoring, and treatment of osteoporosis in childhood, with emphasis on the key pediatric-specific biological principles that are pivotal to the overall approach and on the main questions with which clinicians struggle during routine care. The scope of this chapter is to review the manifestations of and risk factors for primary and secondary osteoporosis in children, to discuss the definition of pediatric osteoporosis, and to provide specific recommendations for monitoring and prevention. This chapter also reviews when a child is a candidate for osteoporosis therapy, which agents and doses should be prescribed, duration of therapy, how the response to therapy is evaluated, and side effects. With this information, the bone health clinician will be poised to diagnose osteoporosis in children, to identify when children need osteoporosis therapy and the clinical outcomes that gauge efficacy and safety of treatment.