Abstract
Type 1 diabetes (T1D) often begins in childhood, a critical period for bone mass accrual and skeletal development. Emerging evidence suggests that pediatric T1D is associated with bone deficits beyond areal bone mineral density (aBMD), including impaired microarchitecture, altered geometry, and reduced estimated strength, which may increase fracture risk across the lifespan. This systematic review aimed to synthesize evidence on (i) the pathophysiological mechanisms by which pediatric T1D alters bone mineral density and skeletal development, and (ii) evidence-supported therapeutic strategies to improve bone accrual in children and adolescents with T1D. A systematic search was performed in PubMed and the Semantic Scholar corpus. Studies were eligible if they included pediatric populations with T1D, reported bone-related outcomes, and were original research. Study selection followed PRISMA 2020 guidelines. Thirty studies met inclusion criteria and were synthesized narratively. Pediatric T1D was associated with mild-to-moderate deficits in bone accrual, particularly with poor glycemic control. Advanced imaging revealed consistent alterations in trabecular microarchitecture, cortical geometry, and estimated bone strength, often despite normal DXA Z-scores. Biochemically, a low-turnover phenotype was commonly observed. Mechanistic correlates included altered GH/IGF-1 axis, increased urinary calcium excretion, elevated Wnt inhibitors (DKK-1), and advanced glycation end-product accumulation. Therapeutic evidence supported calcium/vitamin D supplementation and highlighted the importance of glycemic optimization, weight-bearing physical activity, and management of comorbidities such as celiac disease. Direct interventional evidence for glycemic technologies or structured exercise programs with bone endpoints remains limited. Pediatric T1D negatively impacts skeletal development through multiple mechanisms, with microstructural deficits often exceeding DXA-derived findings. Optimizing calcium/vitamin D status, glycemic control, and physical activity represents promising strategies, but future longitudinal studies are needed.