ABSTRACT: BACKGROUND: Exposure to cadmium has been associated with osteoporosis and fracture risk in women and elderly, but studies in children are lacking. In the present study we investigate the association between markers of bone demineralization [urinary calcium (Ca) and deoxypyridinoline (DPD) excretion] and urinary cadmium (Cd) excretion (as an index of lifetime body burden). METHODS: 155 schoolchildren from 2 elementary schools in Lahore, Pakistan were included. Urinary Cd was measured as an index of lifetime exposure. We assessed the multivariate-adjusted association of exposure with markers of bone resorption, urinary DPD as well as with Ca excretion. RESULTS: Urinary Cd averaged 0.50 nmol/mmol creatinine and was not influenced by age, height, weight and socio-economic status (SES). Independent of gender, age, height, weight and SES a doubling of urinary Cd was associated with a 1.72 times (p<0.0001) increase in urinary DPD and, a 1.21 times (p=0.02) increase in urinary Ca. Additional adjustment for urinary Ca revealed still significant associations between urinary Cd and urinary DPD. The shape of the association was linear without evidence of a threshold. CONCLUSIONS: Even in young children, low-level environmental exposure to cadmium is associated with evidence of bone resorption, suggesting a direct osteotoxic effect with increased calciuria. These findings might have clinical relevance at older age.