Bisphosphonates are increasingly prescribed for children with primary and secondary osteoporosis. Despite this, many questions remain as to the optimal agent, and the dose and duration of therapy, particularly considering the unique issues related to the growing skeleton. While much is now understood regarding their use in one of the most debilitating forms of childhood osteoporosis (osteogenesis imperfecta), their role in the treatment of secondary osteoporosis is less clearly defined. The purpose of this review is to highlight the impact of bisphosphonate use on the growing skeleton and to review the current evidence for bisphosphonate administration in primary and secondary childhood osteoporosis. In particular, we discuss the evidence for clinical benefit (including functional outcomes beyond bone mineral density) and review the issues related to known and theoretical side effects. Finally, we provide specific recommendations for the use of bisphosphonates in pediatric osteoporosis, including guidelines for monitoring treatment outcomes. This review has been developed for educational purposes by the Drugs and Therapeutics Committee of the Lawson Wilkins Pediatric Endocrine Society.